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MCN Book Project
Note: Secretions from both of these Skenes’s and Bartholin’s glands help to lubricate
the external genitalia during coitus. The alkaline pH of their secretions helps to
improve sperm survival in the vagina. Both Skene's glands and Bartholin's glands
may become infected and produce a discharge and local pain.
L. Vestibular fossa (navicular fossa)- is a boat-shaped depression between the
vagina/hymen and the frenulum labiorum pudendi.
M. Perineum – area from the lower border of the vaginal orifice to the anus; contains the
muscles (e.g., pubococcygeal and levator ani) which support the pelvic organs, the
arteries that supply blood and the pudendal nerves which are important during
delivery under anesthesia.
Figure 1.2 Anterior view of female reproductive organs indicating the relationship of fallopian tubes
and body of the uterus.
A. Vagina – a 3-4 inch long dilatable canal located between the bladder and the rectum;
contains rugae (which permit considerable stretching without tearing); passageway
for menstrual discharges, copulation and fetus. CBQ
B. Uterus – hollow pear-shaped fibromuscular organ 3 inches long, 2 inches wide, 1
inch thick, and weighing 50-60 grams in a non-pregnant woman; hold in place by
broad ligaments (from sides of the uterus to pelvic wall; also hold Fallopian tubes and
ovaries in place) and round ligaments (from sides of uterus to mons pubis); abundant
blood supply from uterine and ovarian arteries; composed of three muscle layers
(perimetrium, myometrium, and endometrium). Consists of three parts: corpus
(body) – upper portion with triangular part called fundus; isthmus – area between
corpus and cervix which forms part of the lower uterine segment; and, - cylindrical
portion. Organ of menstruation, site of implantation and retainment and nourishment
of the products of conception. Main support comes from cardinal ligaments
C. Fallopian Tubes – 4 inches long from each side of the fundus; widest part (called
ampulla) spreads into fingerlike projections (called fimbriae). Responsible for
transport of mature ovum from ovary to uterus; fertilization takes place in its outer
third or outer half.
D. Ovaries – almond-shaped, dull white sex glands near the fimbriae, kept in place by
ligaments. Produce, mature and expel ova and manufacture estrogen and
progesterone.
A. Structure
1. 2 Os Coxae/Innominate bones – made up of:
a. Ilium – upper, extended part; curved upper border is the iliac crest.
b. Ischium – under part; when sitting, the body rests on the ischial
tuberosities; ischial spines are important landmarks.
c. Pubes – front part; join to form an articulation of the pelvis called
the symphysis pubis.
2. Sacrum – wedge-shaped, form the back part of the pelvis. Consists of 5
fused vertebrae, the first having a prominent under margin called the sacral
promontory. Articulates with the ilium, the sacroiliac joint.
3. Coccyx – lowest part of the spine; degree of movement between sacrum
and coccyx, made possible by the third articulation of the pelvis called
sacrococcygeal joint which allows room for delivery of the fetal head.
B. Divisions – set apart by the linea terminalis, (pelvic brim, ileopectineal line) and
imaginary line from the sacral promontory to the ilia on both side to the superior
portion of the symphysis pubic.
1. False pelvis – superior half formed by the ilia. Offers landmarks for pelvic
measurements; supports the growing uterus during pregnancy; and directs
the fetus into the true pelvis near the end of gestation.
2. True pelvis – inferior half formed by the pubis in front, the ilia and the ischia
on the sides and the sacrum and coccyx behind. Made up of three parts:
a. Inlet – entranceway to the true pelvis. Its transverse diameter is wider
than its anteroposterior diameter. Thus:
Transverse diameter = 13.5 cm
Anteroposterior diameter = 11 cm
Right and left oblique diameters = 12.75 cm
b. Cavity – space between the inlet and outlet
c. Outlet – inferior portion of the pelvis bounded in the back by the coccyx,
on the sides by the ischial tuberosities and in front by the inferior aspect of
the symphysis pubis and the pubic arch. Its anteroposterior (AP) diameter is
wider than its transverse diameter.
C. Types/Variations
1. Gynecoid – “normal female pelvis. Inlet is well rounded forward and back.
Most ideal for childbirth.
2. Anthropoid – transverse diameter is narrow, AP diameter is larger than
normal.
3. Platypelloid – inlet is oval, AP diameter is shallow
4. Android – “male” pelvis. Inlet has a narrow, shallow posterior portion and
pointed anterior portion.
D. Measurements
1. External – suggestive only of pelvic site.
a. Intercristal – distance between the middle points of the iliac crests.
Average = 28 cm.
b. Interspinous – distance between the anterosuperior iliac spines.
Average = 25 cm.
c. Intertrochanteric – distance between the trochanters of the femur.
Average = 31 cm.
d. External conjugate/Daudelocque’s – the distance between the anterior
aspect of the symphysis pubis and depression below L5. Average = 18-20
cm.
2. Internal – give the actual diameters of the inlet and outlet
a. Diagonal conjugate – distance between sacral promontory and inferior
margin of the symphysis pubis. Average = 12.5 cm.
b. True conjugate/conjugata vera – distance between the anterior surface
of the sacral promontory and the superior margin of the symphysis pubis.
Very important measurement because it is the diameter of the pelvic inlet.
Average = 10.5 - 11 cm.
c. Bi-ischial diameter/tuberischial – transverse diameter of the pelvic
outlet. Is measured at the level of the anus. Average = 11 cm
A. General Considerations
1. 300,000 – 400,000 immature oocytes per ovary are present at birth (ware
formed during the first 5 months of intrauterine life); many, however,
degenerate and atrophy (process called atresia). About 300 – 400 mature
during the entire reproductive cycle of women.
2. Ushered in by the menarche, (first menstruation in girls) and ends with
menopause (permanent cessation of menstruation; no more functioning
oocytes in the ovaries). Age of onset and termination vary widely, depending
on heredity, racial background, nutrition and climate.
3. Normal period (days when there is menstrual flow) lasts for 3-6 days;
menstrual cycle (from first day of menstrual period to first day of next
menstrual period) maybe anywhere from 25-35 days, but accepted average
length in 28 days.
4. Anovulatory states after menarche not unusual because of immaturity of
feedback mechanism (anovulatory states occur also in pregnancy, lactation
and related disease conditions).
5. Associated terms:
a. Amenorrhea – temporary cessation of menstrual flow
b. Oligomenorrhea – markedly diminished menstrual flow, nearing
amenorrhea
c. Menorrhagia – excessive bleeding during regular menstruation
d. Metrorrhagia – bleeding at completely irregular intervals
e. Polymenorrhea – frequent menstruation occurring at intervals of less
than three weeks
6. Body structures involved:
a. Hypothalamus
b. Anterior pituitary gland
c. Ovary
d. Uterus
7. Hormones which regulate cyclic activities:
a. Follicle-stimulation hormone (FSH)
b. Luteinizing hormone (LH)
8. Effects of estrogen in the body:
a. Inhibits production of FSH
b. Causes hypertrophy of the endometrium
c. Stimulates growth of the ductile structures of the breasts
d. Increases quantity and pH of cervical mucus, causing it to become thin and
watery and can be stretched to a distance of 10-13 cm. (Spinnbarkeit test of ovulation)
9. Effects of progesterone in the body:
a. Inhibits production of LH
b. Increases endometrial tortuosity
c. Increases endometrial secretions
d. Inhibits uterine motility
e. Decreases muscle tone of gastrointestinal and urinary tracts
f. Increases musculoskeletal motility
g. Facilitates transport of the fertilized ovum through the Fallopian tubes
h. Decreases renal threshold for lactose and dextrose
i. Increases fibrinogen levels; decreases hemoglobin and hematocrit
j. Increases body temperature after ovulation. Just before ovulation, basal
body temperature decreases slightly (because of low progesterone level in the blood) and then
increases slightly a day after ovulation (because of the presence of progesterone).
C. Additional Information
1. When the ovary releases the mature ovum on the day of ovulation,
sometimes a certain degree of pain in either the right or left lower quadrant is
felt by the woman. This sensation is normal and is termed mittelschmerz.
2. The first 14 days of the menstrual cycle is a very variable period. The last 14
days of the menstrual cycle is a fixed period exactly 2 weeks after ovulation,
menstruation will occur (unless a pregnancy has taken place) because the
corpus luteum has a life span of only 2 weeks. Implication: when given
options regarding the exact date of ovulation, choose two weeks before
menstruation.
3. In a 28-day cycle, ovulation takes place on the 14 th day. In a 32-day cycle,
ovulation takes place on the 18 th day. In a 26-day cycle, ovulation takes
place or the 12th day (Subtract 14 days from the cycle).
4. Menstruation can occur even without ovulation (as in women taking oral
contraceptives). Ovulation can likewise occur even without menstruation (as
in lactating mothers).
PREGNANCY AND PRENATAL CARE
II. Fertilization
A. Definition: the union of the sperm and the mature ovum in the outer third or outer half of
the Fallopian tube.
B. General considerations:
1. Normal amount of semen per ejaculation = 3 – 5 cc = 1 teaspoon
2. Number of sperms in an ejaculate = 120 – 150 million/cc
3. Mature ovum is capable of being fertilized for 12-24 hours after ovulation.
Sperms are capable of fertilizing even for 3-4 days after ejaculation
4. Normal life span of sperms = 7 days
5. Sperms, once deposited in the vagina, will generally reach the cervix within 90
seconds after deposition.
6. Reproductive cells, during gametogenosis, divide by meiosis (haploid number of
daughter cells); therefore, they contain only 23 chromosomes (the rest of the body cells have 46
chromosomes). Sperms have 22 autosomes and 1 X sex chromosome or 1 Y sex chromosome;
ova contain 22 autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a
mature ovum results in a baby girl (XX); the union of a Y-carrying sperm and a mature ovum
results in a baby boy (XY). Important: Only fathers determine the sex of their children.
III. 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 blastomeres, it is now terms a morula. In
this morula form, it will start to travel (by ciliary action and peristaltic contractions of the Fallopian
tube) to the uterus where it will stay for another 3-4 days. When there is already a cavity formed
in the morula, it is now called blastocyst. Fingerlike projections, called trophoblasts, form
around the blastocyst and these trophoblast are the once which will implant high on trophoblasts
or posterior surface of the uterus. Thus, implantation, also called nidation, takes place about a
week after fertilization.
General Consideration:
A. Once implantation has taken place, the uterine endothelium is now termed decidua
B. Occasionally, a small amount of vaginal spotting appears with implantation because
capillaries are ruptured by the implanting throphoblasts = implantation bleeding.
Implication: this should not be mistaken for the Last Menstrual Period (LMP).
2. Chorion – together with the deciduas basalis gives rise to the placenta, which starts to
form on the 8th week of gestation. Develops into 15-20 subdivision called
cotyledons. Placenta serves the following purposes:
a. Respiratory system – exchange of gases takes place in the placenta, not in the fetal
lungs
b. Renal system – waste products are being excreted through the placenta (Note: it is
the mother’s liver which detoxifies the fetal waste products).
c. Gastrointestinal system – nutrients pass to the fetus via the placenta by diffusion
through the placental tissues.
d. Circulatory system – feto-placental circulation is established by selective osmosis
e. Endocrine system – it produces the following hormones (before 8 weeks gestation,
the corpus luteum is the one producing these hormones):
Human chronionic gonadotropin (HCG) – “order’s the corpus luteum to
keep on producing estrogen and progesterone that is why menstruation does
not ta ke place during pregnancy. It is also the basis for pregnancy test.
Human placental lactogen (HPL)/human chronionic somatomammotropin
– promotes growth of the mammary glands necessary for lactation. Also has
growth-stimulating properties
Estrogen
Progesterone
f. Protective barrier – inhibit passage of some bacteria and large molecules.
A. Systemic Changes
1. Circulatory/Cardiovascular
a. Beginning the end of the first trimester, there is gradual increase of about 30%-
50% in total cardiac volume, reaching its peak during the 6 th month. This causes
a drop in hemoglobin and hematocrit values since the increase is only in the
plasma volume=physiologic anemia of pregnancy. Consequences of increased
total cardiac volume are:
Easy fatigability and shortness of breath because of increased workload of
the heart
Slight hypertrophy of the heart, causing it to be displaced to the left,
resulting in torsion on the great vessels (the aorta and pulmonary artery)
Systolic murmurs are common due to lowered blood viscosity
Nosebleeds may occur because of marked congestion of the nasopharynx
as pregnancy progresses
b. Palpitations due to:
Sympathetic nervous system stimulation during first half of pregnancy
Increased pressure of uterus against the diaphragm during 2 nd half of
pregnancy
c. Because of poor circulation resulting from pressure of the gravid uterus on the
blood vessels of the lower extremities:
Edema of the lower extremities occurs.
Management: raise legs above hip level
Important: Edema of the lower extremities is NOT a sign of toxemia.
Varicosities of the lower extremities can also occur. Management:
Use/wear support hose or elastic stocking to promote
venous flow, thus preventive stasis in the lower extremities
Apply elastic bandage – start at the distal end of the
extremity and work toward the trunk to avoid congestion and
impaired circulation in the distal part; do not wrap toes so as
to be able to determine the adequacy of circulation (Principle
behind bandaging: blood flow thru tissues is decreased by
applying excessive pressure on blood vessels)
Avoid use of constricting garters, e.g., knee-high socks
d. Because of poor circulation in the blood vessels of the genitalia due to pressure of
the gravid uterus, varicosities of the vulva and rectum can occur. Management:
Side-lying position with hips elevated on pillows
Advise modified knee-chest position
e. There is increased level of circulating fibrinogen, that is why pregnant women are
normally safeguarded against undue bleeding. However, this also predisposes
them to formation of blood clots (thrombi). The implication is that pregnant
women should not be massaged since blood clots can be released an cause
thromboembolism.
2. Gastrointestinal changes
a. Morning sickness (-nausea and vomiting during the first trimester) is due to
increased human chorionic genadotropin (HCC). It may also be due to increased
acidity or even to emotional factors. Management:
Eat dry toast or crackers 30 minutes before arising in the morning (or dry,
high carbohydrate, low fat and low spices in the diet).
Hyperemesis gravidarum – excessive nausea and vomiting which persists
beyond 3 months; will result in dehydration, starvation and acidosis.
Management
D10 NSS 3000 ml in 24 hours is the priority of treatment
Complete bed rest is also an important
b. Constipation and flatulence are due to the displacement of the stomach and
intestines, thus slowing peristalsis and gastric-emptying time; may also be due to
increased progesterone during pregnancy. Management:
Increase fluids and roughage in the diet
Establish regular elimination time
Increase exercise
Avoid enemas
Avoid harsh laxatives like Dulcolax; stool softeners, e.g. Colace, are better
Mineral oil should not be taken because it interferes with absorption of fat-
soluble vitamins
c. Hemorrhoids are due to pressure of enlarged uterus. Management:
Cold compress with witch hazel or Epsom salts.
d. Heartburn, especially during the last trimester, is due to increased progesterone
which decreases gastric motility, thereby causing reverse peristaltic waves which
lead to regurgitation of stomach contents through the cardiac sphincter into the
esophagus, causing irritation.
Management:
Pats of butter before meals
Avoid fried, fatty foods
Sips of milk at frequent intervals
Small, frequent meals taken slowly
Bend at the knees, not at the waist
Take antacids (e.g. Milk of Magnesia) but NEVER sodium bicarbonate
(e.g. Alka Seltzer or baking soda) because it promotes fluid retention.
5. Musculoskeletal changes
a. Because of the pregnant woman’s attempt to change her center of gravity, she
makes ambulation easier by standing more straight and taller, resulting in a
lordotic position (“pride of pregnancy”)
b. Due to increased production of the hormone relaxin, pelvic bones become more
supple and movable, increasing the incidence of accidental falls due to the
wobbly gait.
Implication: Advise use of low-heeled shoes after the first trimester.
c. Leg cramps are caused by:
Increased pressure of gravid uterus on lower extremities
Fatigue
Chills
Muscle tenseness
Low calcium high phosphorus intake
Management:
Frequent rest periods with feet elevated
Wear warm, more comfortable clothing
Increase calcium intake (calcium tablets and diet)
Do not massage – blood clots can cause embolism
Most effective relief: Press knee of the affected leg and dorsiflex the foot
7. Endocrine changes
a. Addition of the placenta as an endocrine organ, producing large amounts of
estrogen, progesterone, HCG and HPL
b. Moderate enlargement of the thyroid gland due to hyperplasia of the glandular
tissues and increased vascularity. Could also be due to increased basal
metabolic activity of the products of conception.
c. Increased size of the parathyroids, probably to satisfy the increased need of
the fetus for calcium
d. Increased size and activity of the adrenal cortex, thus increasing the amount of
circulating cortisol, aldosterone and ADH, all of which affect carbohydrate
and fat metabolism
e. Gradual increase in insulin production but the body’s sensitivity to insulin is
decreased during pregnancy
8. Weight
a. During first trimester, weight gain of 1.5 – 3 lbs
b. On 2nd trimester and 3rd trimesters, weight gain of 10-11 pounds per trimester
is recommended
c. Total allowable weight gain during entire period of pregnancy is 20 - 25 lbs ( =
10 – 12 kgs)
d. Pattern of weight gain is more important than the amount of weight gained
e. Distribution of weight gain during pregnancy:
Fetus 7 lbs
Placenta 1 lb
Amniotic fluid 1 ½ lbs
Increased weight of uterus 2 lbs
Increased blood volume 1 lb
Increased weight of the breast 1 ½ - 3 lbs
Weight of additional fluid 2 lbs
Fat fluid accumulation 4 – 6 lbs
Characteristic of pregnancy _________
TOTAL = 20 – 25 lbs
9. Emotional responses
a. First trimester: the fetus is an unidentified concept with great future
implications but without tangible evidence of reality. Some degree of
rejection, denial and disbelief, even repression. (Implication: when giving
health teachings, be sure to emphasize the bodily changes in pregnancy)
b. Second trimester: fetus is perceived as a separate entity. Fantasizes
appearance of the baby
c. Third trimester: has personal identification with a real baby about to be
born and realistic plans for future child care responsibilities. Best time to talk
about preparation of layette and infant feeding method. Fear of death,
though, is prominent (To allay fears, let pregnant woman listen to the fetal
heart tones).
B. Local Changes
1. Uterus
a. Weight in crease to about 1,000 grams at full term; due to increase in the
amount of fibrous and elastic tissues.
b. Change in shape from pear-like to ovoid
c. Change in consistency of the lower uterine segment causes extreme softening,
known as Hegar’s sign, seen at about the 6th week
d. Mucous plugs in the cervix, called operculum, are produced to seal out
bacteria
e. Cervix becomes more vascular and edematous, resembling the consistency of
an earlobe, known as Goodell’s sign.
2. Vagina
a. Increased vascularity causes change in color from light pink to deep purple or
violet known as Chadwick’s sign
To prevent confusion as to pregnancy signs arrange the body “out to
xxx” and the different signs alphabetically. Thus:
Vagina - Chadwick’s sign
Cervix - Goodell’s sign
Uterus - Hegar’s sign
b. Due to increase estrogen, activity of the epithelial cells increases, thus
increasing amount of vaginal discharges called leukorrhea. As long as the
discharges are not smelling or irritatingly itchy, it is normal. Management:
Maintain or increase cleanliness by taking twice daily shower baths using
cool water.
c. pH of vagina changes from the normally acidic (because of the presence of the
Doderlein bacilli) to alkaline (because of increased estrogen). Alkaline
vaginal environment is supposed to protect against bacterial infection,
however, there are two microorganisms which love to thrive in an alkaline
environment:
Trichomonas, a protozoa or flagellate. The condition is called trichomonas
vaginalis or trichomonas vaginitis or trichomoniasis. Symptoms are:
Frothy, cream-colored, irritatingly itchy, foul-smelling discharges
Vulvar edema and hyperemia due to irritation from the discharges
Treatment:
Flagyl for 10 days p.o. or vaginal suppositories of Trichomonicidal
compounds (e.g., Tricefuron, Vagisec, Devegan). Note: Is
carcinogenic during the first trimester. Treat male partner also,
with Flagyl. (Important: avoid alcoholic drinks when taking Flagyl –
can cause Antabuse-like reactions: vomiting, flushed face and
abdominal cramps.) Dark brown urine a minor side effect-no need
to discontinue the drug.
Acidic vaginal douche (1 tbsp. white vinegar to 1 quart of water or
15 ml white vinegar in 1000 ml water) to counteract alkaline-
preferred environment of the protozoa.
Avoid intercourse to prevent re-infection.
Monilia, a fungus called Candida albicans. The condition is called
Moniliasis or Candidiasis. Fungus also lives to thrive in
environment right in carbohydrates (that is why it is common
among poorly-controlled diabetics) and in those on steroid and
antibiotic therapy when acidic environment is altered.
Symptoms:
White, patchy, cheese-like particles that adhere to vaginal walls.
Irritatingly itchy and foul-smelling vaginal discharges
Treatment:
Mycostatin/Nystatin p.o. or vaginal
suppositories/pessaries (100,000 U) twice a day for 15 days
Gentian violet swab to vagina (use panty shields to
prevent staining of clothes or underwear)
Correct diabetes
Avoid intercourse
Acidic vaginal douche
Moniliasis is seen as oral thrush in the newborn when transmitted
during delivery through the birth canal of the infected mother.
3. Abdominal Wall
a. Striae gravidarum – increased uterine size results in rupture and atrophy
of the connective tissue layers, seen as pink or reddish streaks (gently
rubbing oil on the skin helps prevent diastasis)
b. Umbilicus pushed out
4. Skin
a. Linea nigra – brown line running from umbilicus to symphysis pubis
b. Melasma or chloasma – extra pigmentation on cheeks and across the
nose due to the increased production of melanocytes by the pituitary
gland
c. Sweat glands unduly activated
5. Breasts
a. All changes due to increased estrogen
b. Increase in size due to hyperplasia of mammary alveoli and fat deposits.
Proper breast support with well-fitting brassiere necessary to prevent
sagging
c. Feeling of fullness and tingling sensation in the breasts
d. Nipples more erect (For mothers who intend to breastfeed, advise nipple
rolling, drying nipples with rough towel to help toughen the nipples and
not to use soap or alcohol so as to prevent drying which could lead to
sore nipples).
e. Montgomery glands become bigger and more protruberant
f. Areolae become darker and diameter increase
g. Skin surrounding areolas turns dark
h. By the fourth month, a thin, watery, high-protein fluid, called colostrums, is
formed. It is the precursor of breast milk.
6. Ovaries – no activity whatsoever, since ovulation does not take place during
pregnancy and progesterone and estrogen are being produced by the
placenta.
The provision of prenatal care is the primary factor in the improvement of maternal
morbidity and mortality statistics. To ensure the success of the prenatal care programs, it should
be remembered that the patient’s understanding of the modalities of care is basic to cooperative
action.
The duration of normal pregnancy is 266-280 days or 38-42 weeks (average is 40 weeks)
or 9 calendar months or 10 lunar months. Any baby, therefore, who is born before the 38 th week
of gestation is called preterm and a baby born after the 42 nd week of gestation is said to be post
term.
A. Diagnosis of Pregnancy
1. Urine examination – human chorionic gonadotropin (HCG) in the urine is the basis
for pregnancy tests. It is present from the 40 th day through the 100th day, reaching
a peak level on the 60th day. HCG, therefore, is most correct 6 weeks after the
LMP. When collecting urine for pregnancy testing:
a. No water taken after 8 PM the night before urine collection in order to
concentrate urine
b. First morning urine, midstream, should be collected in a clean, dry jar
c. If more than 1 hour would lapse before being tested, refrigerate specimen
because HCG is unstable under room temperature
d. Types of urine exams for pregnancy:
Biological tests – presence of HCG will produce hemorrhagic changes in the
ovaries/testes of the animal when the urine of a pregnant woman is injected.
E.g. Ascheim-Zondek – mice; Freidman – rabbit; Frank Berman – rat;
Hogben – toad; male frog. Is actually obsolete.
Immunodiagnostic tests – antigen-antibody reaction. Widely used at present
because results are obtained faster and do not involved the sacrifice of an
animal. E.g. Gravindex; Pregnex; Prognosticon
2. Progesterone Withdrawal Test – also a test to diagnose pregnancy. A
contraceptive pill is taken by the woman three times a day for 3 days pregnancy
test pill (Gestex) is taken once. If menstruation occurs within 10-15 days after, the
woman is not pregnant. If pregnant, there will be no menstruation because the
corpus luteum produces enough hormones to neutralize the effect of withdrawn
synthetic progesterone.
3. Important Estimates
a. Estimates of age of gestation (AOG):
Naegele’s Rule – calculation of expected date of confinement (EDC). Count
back three months from the first day of the last menstrual period (LMP) then
add 7 days. Substitute number for month for easy computation.
McDonald’s Method – determines age of gestation by measuring from the
fundus to the symphysis pubis (in cm.) then divide by 4 = AOG in months.
E.g., fundic height of 16 cm. divided by 4 = 4 months AOG = 16 weeks
AOG.
Bartholomew’s Rule – estimates AOG by the relative position of the uterus in
the abdominal cavity.
o By the 3rd lunar month, the fundus is palpable slightly above the
symphysis pubis
o On the 5th lunar month, the fundus is at the level of the umbilicus
o On the 9th lunar month, the fundus is below the xiphoid process
b. Arey’s Rule – determines the length of the fetus in centimeters.
During the first half of pregnancy, square the number of the month (E.g., first
lunar month: 1 x 1 = 1 cm.)
During the second half of pregnancy, multiply the month by 5 (E.g., 6 th lunar
month: 6 x 5 = 30 cm.)
o Vitamin D – fish, liver, eggs, milk (excess Vit. D during pregnancy can
lead to fetal cardiac problems
o Vitamin E – green leafy vegetables, fish
o Vitamin C – tomatoes, guava, papaya
o Vitamin B – foods rich in proteins
o Calcium/phosphorus – milk, cheese
o Iron – especially important during the last trimester when the pregnant
woman is going to transfer her iron stores from herself to her
fetus so that the baby has enough iron stores during the first 3
months of life when all he takes is milk (which is deficient in
iron). Iron has a very low absorption rate; only 10% of the iron
intake can be absorbed by the body. Thus, for optimum
absorption, give Vitamin C. Iron should be given after meals
because it is irritating to the gastric mucosa. Sources: liver
and other internal organs camote tops, kangkong, egg yolk,
ampalaya.
* Malnutrition during pregnancy can result in prematurity, preeclampsia, abortion, low birth
weight babies, congenital defects or even stillbirths.
A. Importance – From an obstetrical point of view the fetal skull is the most important part of
the fetus because:
1. It is the largest part of the body
2. It is the most frequent presenting part
3. It is the least compressible of all parts
B. Cranial bones – the first 3 are not important because they lie at the base of the cranium
and, therefore, are never the presenting parts:
1. Sphenoid
2. Ethmoid
3. Temporal
4. Frontal
5. Occipital
6. Parietal
C. Membrane spaces – suture lines are important because they allow the bones to move and
overlap; changing the shape of the fetal head in order to fit through the birth canal, a
process called molding:
1. Sagittal suture line – the membranous interspace which joins the 2 parietal bones
2. Coronal suture line – the membranous inter-space which joins the frontal bone and
the parietal bones
3. Lambdoid suture line – the membranous inter-space which joins the occiput and the
parietals
Which one of these diameters is presented at the birth canal depends on the degree
of flexion (known as attitude) the fetal head assumes prior to delivery. In full flexion (very good
attitude when the chin is flexed on the chest), the smallest suboccipitobregmatic diameter is the
one presented at the birth canal. If in poor flexion, the widest occipitomental diameter will be the
one presented and will give mother and baby more problems
D. Prostaglandin theory – initiation of labor is said to result from the release of arachidonic
an acid produced by steroid action on lipid precursors. Arachidonic acid, is said to
increase prostaglandin synthesis which, in turn, causes uterine contractions.
E. Theory of Aging Placenta – because of the decreased blood supply, the uterus contracts.
A. Lightening – the settling of the fetal head into the pelvic brim. In primis, it occur 2 weeks
before EDC; in multis, on or before labor onset.
Results of lightening:
1. Increase in urinary frequency
2. Relief of abdominal tightness and diaphragmatic pressure
3. Shooting pains down to legs because of pressure on the sciatic nerve
4. Increase in the amount of vaginal discharges.
5. Lightening should not be confused with engagement. Engagement occurs when the
presenting part has descended into the pelvic inlet.
B. Increased Activity Level – due to increase in epinephrine secreted to prepare the body for
the coming “work” ahead. Advise the pregnant woman not to use this increased energy
for doing household chores.
C. Loss of weight – of about 2-3 lbs 1 to 2 days before labor onset, probably due to
decrease in progesterone production, leading to decrease in fluid
retention.
E. Ripening of the cervix – from Goodell’s sign, the cervix becomes “butter-soft”.
A. Uterine Contractions – the surest sign that labor has begun is the initiation of effective,
productive uterine contractions.
1. Pain in uterine contractions results from:
a. Contraction of uterine muscles when in an ischemic state
b. Pressure on nerve ganglia in the cervix and lower uterine segment
c. Stretching of ligaments adjacent to the uterus and in the pelvic joints
d. Stretching and displacement of the tissues of the vulva and perineum
2. Phases of uterine contractions
a. Increment – first phase during which the intensity of contraction increases; also
known as crescendo
b. Acme – the height of the uterine contraction; also know as apex
c. Decrement – last phase during which intensity of contraction decreases; also
known as decrescendo
3. No increase in duration, frequency and 4. Continue no matter what the woman’s level
intensity of activity is.
B. Effacement – shortening and thinning of the cervical canal from 1-2 cm. to one in which no
canal as distinct from the uterus exists. It is expressed in percentage.
Primis Multis
A. First Stage (Stage of Dilatation) – begins with true labor pains and ends with complete
dilatation of the cervix.
1. Power/Forces: Involuntary uterine contractions
2. Phases:
a. Latent – early time in labor
Cervical dilatation is minimal because effacement is occurring
Cervix dilates 3-4 cm. only
Contractions are of short duration and occur regularly 5-10 minutes apart
(during which time the pregnant woman may seek admission to the
hospital)
Mother is excited, with some degree of apprehension but still with ability to
communicated
Takes up 8 of the 12-hour first stage
b. Active/accelerated
Cervical dilatation reaches 4-8 cm.
Rapid increase in duration, frequency and intensity of contractions
Mother fears losing control of herself
2. Nursing Care
a. Hospital admission – provide privacy and reassurance from the very start
Personal data – name, age, address, civil status
Obstetrical data – determine EDC; obstetrical score; amount and character of
show; and whether or not membranes have ruptured
b. General physical examination, internal exam and Leopold’s maneuvers are done
to determine:
Effacement and dilatation
Station – relationship of the fetal presenting part to the level of the ischial
spines
Station 0 – at the level of the ischial spines; synonymous
to engagement
Station -1 – presenting part above the level of the ischial
spines
Station +1 – presenting part below the level of the ischial
spines
Station +3 or +4 – synonymous to crowning (=
encirclement of the largest diameter of the fetal
had by the vulvar ring)
Presentation – relationship of the long axis of the fetus to the long axis of the
mother; also known as lie
Presenting part – the fetal part which enter the pelvis first and covers the
internal cervical os
Table 6. Types of Presentation
I. VERTICAL
A. Cephalic – he is the presenting part
1. Vertex – head sharply flexed, making the parietal bone the presenting part
2. Face)
3. Brow) if in poor flexion
4. Chin )
In vertex and breech presentations, fetal heart sounds are best heard, at the area
of the fetal back; in face presentations, at the area of the fetal chest
In vertex presentations, FHS are usually located in either the left or right lower
quadrant (RLQ or LLQ); in breech presentation, at or above the level of the
umbilicus (RUQ or LUQ)
Hazards of breech delivery:
o Cord compression
o Abruptio placenta
o Erb-duchenne paralysis
Horizontal lie is very rare (1%) and maybe due to a relaxed abdominal wall
because of multiparity, pelvic contraction or placenta previa
Position – relationship of the fetal presenting part to a specific quadrant of the
mother’s pelvis
The pelvis is divided into four quadrants
o Right anterior
o Right posterior
o Left anterior
o Left posterior
o Posteriors positions result in more backaches because of pressure fetal
presenting part on the maternal sacrum
Points of direction in the fetus:
o Occiput – in vertex presentations
o Chin (mentum) – in face presentations
o Buttocks/feet – in breech presentations
o Scapula (acromic) – in horizontal presentation
Possible fetal positions
o Vertex
LOA – left occipitoancetior (most common and favorable position at birth)
LOP – left occipitoposterior
LOT – left occipitoetransverse
ROA – right occipitoanterior
ROP – right occipitoposterior
ROT – right occipitotransverse
o Breech
LSA – left sacroanterior
LSP – left sacroposterior
LST – left sacrotransverse
RSA – right sacroanterior
RSP – right sacroposterior
RST – right sacrotransverse
o Face
LMA – left mentoanterior
LMP – left mentoposterior
LMT – left mentotransverse
RMA – right mentoanterior
RMP – right mentoposterior
RMT – right mentotransverse
o Shoulder
LADA – left acromiodorsoanterior
LADP – left acromiodorsoposterior
RADA – right acromiodorsoanterior
RADP – right acromiodorsotransverse
Vaginal bleeding
Premature labor
Abnormal fetal presentation or position
Ruptured membranes
Crowning
Encourage the mother to void very 2-3 hours by offering the bedpan because:
B. Transition Period – when the mood of the woman suddenly changes and the nature of the
contractions intensify.
1. Characteristics :
a) If membranes are still intact, this period is marked by a sudden gush of
amniotic fluid as fetus is pushed into the birth canal. If spontaneous
rupture does not occur, amniotomy (snipping of BOW with a sterile
pointed instrument e.g. Kelly or Allis forceps or amniohook to allow
amniotic fluid to drain), is done to prevent fetus from aspirating the
amniotic fluid as it makes its different fetal position changes.
Amniotomy, however cannot be if station is still “minus” as this (can lead
to cord compression).
b) Show becomes prominent.
c) There is an uncontrollable urge to push with contractions, a sign of
impending second stage of labor. Profuse perspiration and distention of
neck veins are seen.
d) Nausea and vomiting is a reflex reaction due to decreased gastric
motility and absorption.
e) In primis, baby is delivered within 20 contractions (=40 minutes); in
multis, in 10 contractions (=20 mintues)
C. Second Stage ( stage of Expulsion) – begins with complete dilatation of the cervix and
ends with delivery of the baby.
1.Power/forces : In voluntary uterine contractions and contractions of the
diaphragmatic and abdominal muscles
2.Mechanisms of Labor/ Fetal Position Changes : (D FIRE ERE)
a. Descent ( may be preceded by engagement)
b. Flexion – as descant occurs, pressure from the pelvic floor causes the
chin to bend forward onto the chest
c. Internal Rotation – from AP to transverse, then AP to AP
d. Extension – as head comes out, the back of the neck stops beneath the
pubic arch. The head extends and the forehead, nose, mouth and chin
appear
e. External Rotation ( also called restitution - anterior shoulder rotates
externally to the AP position
f. Expulsion – delivery of the rest of the body
3.Nursing Care
a. When positioning legs or lithotomy, put them up at the same time to
prevent injury to the uterine ligaments
b. As soon as the fetal head crowns, instruct mother not to push, but to pant
instead ( rapid and shallow breathing) to prevent rapid expulsion of the
baby. If panting is deep and rapid, called hyperventilation the patient will
experience light-headedness and tingling sensation of the fingers leading
to carpopedal spasms, because of respiratory alkalosis. Management:
let the patient breath into brown paper bag to recover lost carbon dioxide;
a cupped hand will serve the same purpose.
c. Assist in episiotomy – incision made in the perineum primarily to prevent
lacerations.
Other purpose of episiotomy:
o Prevent prolonged and severe stretching of muscles
supporting bladder or rectum
o Reduce duration of second stage when there is hypertension
or fetal distress
o Enlarge outlet, as in breech presentation or forceps delivery
Types of episiotomy:
o Median – from middle portion of the lower vaginal border
directed towards the anus
o Mediolateral – begun in the midline but directed laterally away
from the anus
Natural anesthesia is used in episiotomy, i.e., no anesthetic is
injected because pressure of fetal presenting part against the
perineum is so intense that nerve endings for pain are momentarily
deadened.
d. Apply the Modified Ritgen’s Maneuver:
Cover the anus with sterile towel and exert upward and forward
pressure on the fetal chin, while exerting gentle pressure with two
fingers on the head to control emerging head. This will not only
support the perineum, thus preventing lacerations, but will also
favor flexion so that the smallest sub-occipitobregmatic diameter of
the fetal head is presented.
Ease the head out and immediately wipe the nose and mouth of
secretions to establish and maintain a patent airway (REMEMBER:
the first principle in the care of the newborn is establish and
maintain a patent airway). (The head should be delivered in
between contractions.)
Insert 2 fingers into the vagina so as to feel for the presence of a
cord looped around the neck (nuchal cord). If so, but loose, slip it
down the shoulders or up over the head; but if tight; clamp cord
twice, an inch apart, and then cut in between.
As the head rotates, deliver the anterior shoulder by exerting a
gentle downward push and then slowly give an upward lift to
deliver the posterior shoulder
While supporting the head and the neck, deliver the rest of the
body. Take note of the exact time of delivery of the baby.
e. Immediately after delivery, newborn should be held below the level of the
mother’s vulva for a few minutes to encourage flow of blood from the
placenta to the baby.
f. The infant is held with his head in a dependent position (-head lower than
the rest of the body) to allow for drainage of secretions. REMEMBER:
Never stimulate a baby to cry unless you have drained him out of his
secretions first.
g. Wrap the bay in a sterile diaper to keep him warm. REMEMBER: Chilling
increases the body’s need for oxygen.
h. Put the bay on the mother’s abdomen. The weight of the baby will help
contract the uterus.
i. Cutting of the cord is postponed until the pulsations have stopped because
it is believe that 50 – 100 ml of blood is flowing from the placenta to the
baby at this time. After cord pulsations have stopped, clamp it twice, an
inch apart, and then cut in between
j. Show the baby to the mother, inform her of the sex and time of delivery
then give the baby to the circulating nurse.
D. Third Stage (Placental Stage) – begins with the delivery of the baby and
ends with the delivery of the placenta.
1.Signs of placental separation:
a. Uterus becoming round and firm again, rising high to the level of the
umbilicus (Calkin’s sign) – the earliest sign of placental separation
b. Sudden gush of blood from the vagina
c. Lengthening of the cord from the vagina
2. Types of placental delivery:
a. Schultz – if placenta separates first at its center and last at its edges, it
tends to fold on itself like an umbrella and presents the fetal surface
which is shiny. 80% of placentas separate in this manner (“Shiny” for
Schultz)
b. Duncan – if placenta separates first at its edges, it slides along the uterine
surface and presents with the maternal surface which is raw, red, beefy,
irregular and “dirty”. Only about 20% of placentas separate this way.
(”Dirty” of Duncan)
3. Nursing Care
a. Do not hurry the expulsion of the placenta by forcefully pulling out the cord
or doing vigorous fundal push as this can cause uterine inversion. Just
watch for the signs of placental separation.
b. Tract the cord slowly, winding it around the clamp until placenta
spontaneously comes out, rotating it slowly so that no membranes are
left inside the uterus, a method called Brandt-Andrews maneuver.
c. Take not of the time of placental delivery; it should be delivered within 20
minutes after the delivery of the baby. Otherwise, refer immediately to
the doctor as this can cause severe bleeding in the mother.
d. Inspect for completeness of cotyledons; any placental fragment retained
can also cause severe bleeding and possible death
e. Palpate the uterus to determine degree of contraction. If relaxed, boggy or
non-contracted, first nursing action is to massage gently and properly.
An ice cap over the abdomen will also help contract the uterus since cold
causes vasoconstriction.
f. Inject oxytocin (Methergin – 0.2. mg/ml or Syntocinon = 10 U/ml) – IM to
maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins
are not given before placental delivery because placental entrapment can
occur.
Categories of lacerations (tend to heal more slowly because of ragged
edges):
o First degree – involves the vaginal mucous membranes and skin
o Second degree – involves not only the vaginal mucous
membranes and skin, but also the muscles
o Third degree – involves not only the muscles, vaginal mucous
membranes and skin, but also the external sphincter of the rectum
o Fourth degree – involves not only the external sphincter of the
rectum, the muscles, vaginal mucous membranes and skin, but
also the mucous membranes of the rectum
Assist the doctor in doing episiorrhaphy (- repair of episiotomy or
lacerations). In vaginal episiorrhaphy, packing is done to maintain
pressure on the suture line, thus prevent further bleeding. Note:
Vaginal packs have to be removed after 24 – 48 hours
g. Make mother comfortable by perineal care and applying clean sanitary napkin
snugly to prevent its moving forward from the anus to the vagina. Soiled
napkins should be removed from front to back.
h. Position the newly-delivered mother flat on bed without pillows to prevent
dizziness due to decrease in intra-abdominal pressure.
i. The newly-delivered mother may suddenly complain of chills due to the rapid
decrease of pressure, fatigue or cold temperature in the delivery room.
Management: Provide additional blankets to keep her warm.
j. May give initial nourishment, e.g., milk, coffee, or tea
k. Allow patient to sleep in order to regain lost energy
E. Fourth Stage – first 1 – 2 hours after delivery which is said to be the most critical stage
for the mother because of unstable vital signs.
1. Assessment:
a. Fundus – should be checked every 15 minutes for 1 hour then every 30
minutes for the next 4 hours. Fundus should be firm, in the midline and,
during the first 12 hours postpartum, is a little above the umbilicus. First
nursing action for a non-contracted uterus: massage.
b. Lochia – should be moderate in amount. Immediately after delivery, a perineal
pad can be completely saturated after 30 minutes.
c. Bladder – a full bladder is evidenced by a fundus which is to the right of the
midline, dark-red bleeding with some clots.
d. Perineum – is normally tender, discolored and edematous. It should be clean,
with intact sutures.
e. Blood pressure and pulse rate – may be slightly increased from excitement
and effort of delivery, but normalize within one hour.
2. Lactation-suppressing agents – estrogen-androgen preparation given within the first
hours postpartum to prevent breastmilk production in mothers who will not (or
cannot) breastfeed. E.g., diethylstilbestrol,
TACE or deladumone. These drugs tend to increase uterine bleeding and retard
menstrual return.
3. Rooming-in concept – mother and baby are together while in the hospital. The
concept of a family, therefore, is felt at the very beginning because parents have
the baby with them, thus providing opportunities for developing a positive
relationship between parents and newborn. Eye-to-eye contact is immediately
established, releasing maternal caretaking responses.
VII. Dystocia – bread term for abnormal or difficult labor and delivery.
A. Uterine Inertia – sluggishness of contractions.
1. Causes:
a. Inappropriate use of analgesics
b. Pelvic bone contraction
c. Poor fetal position
d. Overdistention – due to multiparity, multiple pregnancy, polyhydramnios or
excessively large fetus
2. Types:
a. Primary (hypertonic) Uterine Dysfunction relaxations are inadequate and mild,
this are ineffective. Since uterine muscles are in a state of greater than
normal tension, latest phase of the first stage of labor is prolonged.
Treatment: secure the patient
b. Secondary (hypotonic) Uterine Dysfunction – contractions have been good but
gradually become infrequent and of poor quality and dilatation steps.
Treatment: stimulation of labor either by oxytocin administration or
amniotomy.
B. Precipitate Delivery – labor and delivery that is completed in less than 3 hours after the
onset of true labor pains. Probably due to multiparity or following
oxytocin administration or aminiotomy. Dangers imposed by precipitate
delivery: Extensive lacerations; abruptio placenta; or hemorrhage due to
sudden release of pressure, leading to shock.
C. Prolonged Labor – in primis, labor more than 18 hours and in multis, more than 12
hours. Dangers: maternal exhaustion, uterine atony or caput
succedaneum.
D. Uterine Rupture – occurs when the uterus undergoes more strain that it is capable of
sustaining.
1. Causes:
a. Scar from a previous classic Cesarean Section (CS)
b. Unwise use of oxytocins
c. Overdistention
d. Faulty presentation or prolonged labor
2. Signs and symptoms:
a. Sudden, severe pain
b. Hemorrhage and clinical signs of shock (restlessness, pallor, decreasing BP,
increasing respiratory and pulse rates)
c. Changing abdominal contour, with two swellings on the abdomen, the
retracted uterus and the extrauterine fetus
3. Management: hysterectomy
E. Uterine Inversion – fundus is forced through the cervix so that the uterus is turned inside
out
1. Causes:
a. Insertion of placenta at the fundus, so that as fetus is rapidly delivered,
especially if unsupported, the fundus is pulled down
b. Strong fundal push when mother fails to bear down properly
c. Attempts to deliver the placenta before signs of placental separation appear.
2. Management: hysterectomy
F. Amniotic Fluid Embolism – occurs when amniotic fluid is forced into an open
maternal uterine blood sinus through some defect in the membranes or after partial
premature separation of the placenta. Solid particles in the amniotic fluid enter the
maternal circulation and reach the lungs as emboli.
1. Signs and symptoms – are dramatic:
a. Woman in labor suddenly sits up and grasps her chest because of inability to
breathe and sharp pain
b. Turns pale and then the typical bluish-gray color associated with pulmonary
embolism
c. Death may occur in few minutes
2. Management:
a. Emergency measures to maintain life: IV, oxygen, CPR
b. Provide intensive care in the ICU
c. Keep family informed and provide emotional support
G. Trial Labor – if a woman has borderline (just adequate) pelvic measurements but fetal
position and presentation are good. Maybe continued for as long as there is
progressive fetal descent of the presenting part and cervical dilatation.
1. Management:
a. Monitor FHRs and uterine contractions
b. Keep bladder empty to allow all available space to be used by the fetus
c. Emotional support
H. Premature Labor and Delivery – if uterine contractions occur before the 38 th week of
gestation
1. If there is no bleeding and cervical dilatation and fetal heart sounds are good,
premature uterine contractions can be stopped by drugs:
a. Ethyl alcohol (ethanol) IV – blocks the release of oxytocin. Side effects:
Nausea and vomiting, mental confusion, etc. (same side effects when alcohol
is taken orally in excessive amounts)
b. Vasodilan IV – a vasodilator. Side effects: hypotension and tachycardia
c. Ritodrine – a muscle relaxant given orally
d. Bricanyl – a known bronchodilator
2. If premature uterine contractions are accompanied by progressive fetal descent and
cervical dilatation, premature delivery is inevitable.
a. Not necessarily shorter than full term labor
b. Pain medications are kept to a minimum because analgesics are know to
cause respiratory depression. As it is, premature babies already have
enough difficulty breathing on their own; giving analgesics, therefore, would
add up to the problem. Implication: give emotional support to the mother
such that she focuses her attention not on her own need, but those of her
baby.
c. Steroids (glucocorticoids) are given to the mother to help in maturation of fetal
lungs by hastening production of surfactants.
d. Caudal, spinal or infiltration anesthesia is preferred because it does not
compromise fetal respiration.
e. Episiotomy may not necessarily be smaller than in full-term deliveries; may
even be larger so that the preemie can be delivered the shortest possible
time, since excessive pressure on the fragile preemie’s had can cause
subarachnoid hemorrhage that could be fatal.
f. Forceps may be applied gently.
g. Cord is cut immediately, rather than waiting for pulsations to stop, because
preemies have difficult time excreting large amount of bilirubin that will be
formed from the extra amount of blood.
PUERPERIUM
I. Definitions
A. Promote healing and return to normal (involution) of the different parts of the body.
1. Vascular Changes
a. The 30 – 50% increase in total cardiac volume during pregnancy will be
reabsorbed into the general circulation within 5-10 minutes after placental
delivery. Implication: the first 5-10 minutes after placental delivery is crucial
to gravido-cardiacs because the weak heart may not be able to handle such
workload.
b. White blood cell (WBC) count increases to 20,000-30,000/rm3. Implication:
WBC count, therefore, cannot be sued as an indicator of postpartum
infection.
c. There is extensive activation of the clotting factors, which encourages
thrombo-embolization. This is the reason why:
Ambulation is done early – after 4-8 hours in normal vaginal delivery. When
ambulating the newly-delivered patient for the first time, the nurse should
hold on to the patient’s arm.
Exercises are recommended:
Kegel and abdominal breathing on postpartum day 1 (PPD 1)
Chin-to-chest – on second day to tight on and firm up abdominal muscles
Knee-to-abdomen – when perineum has healed, to strengthen abdominal
and gluteal muscles.
Massage is contraindicated
d. All blood values are back to prenatal levels by the third or fourth week
postpartum
2. Genital changes
a. Uterine involution is assessed by measuring the fundus by fingerbreadths (= 1
cm). On PPD 1 – fundus is one fingerbreadth below the umbilicus; on PPD 2,
2 fingerbreadths below umbilicus and so forth until on the 10 th day
postpartum, it can no longer be palpated because it is already behind the
symphysis pubis.
Subinvoluted uterus – a big uterus and vaginal bleeding with clots. Since
blood clots are good media for bacteria, it is, therefore, a sign of puerperal
sepsis.
b. To encourage return of the uterus to its usual anteflexed position, prone and
knee-chest positions are advised.
c. Afterpains/after birth pains – strong uterine contractions felt more particularly
by multis, those who delivered large babies or twins and those who
breastfeed.
Management:
NEVER apply heat on abdomen
Give analgesics, as ordered
Explain that it is normal and rarely lasts for more than 3 days
d. Lochia – uterine discharge consisting of blood, decidua, WBC mucus and
some bacteria
Pattern:
Rubra – first 3 days postpartum; red and moderate in amount
Serosa – next 4-9 days; pink or brownish and decreased in amount
Alba – from 10th day up to 3-6 weeks; colorless and minimal in amount
Characteristics:
Pattern should not reverse
It should approximate menstrual flow (However, it increases with activity
and decreases with breastfeeding)
It should not have any offensive odor. It has the same fleshy odor as
menstrual blood. Otherwise, it means either poor hygiene or infection
It should not contain large clots
It should never be absent, regardless of method of delivery. Lochia has
the same pattern and amount, whether CS or normal vaginal delivery.
e. Pain in perineal region may be relieved by:
Sim’s position – minimizes strain on the suture line
Perineal heat lamp or warm Sitz baths twice a day – vasodilatation increases
blood supply and, therefore, promotes healing
Application of topical analgesics or administration of mild oral analgesics, as
ordered
f. Sexual activity – maybe resumed by the third or fourth week postpartum if
bleeding has stopped and episiorrhaphy has haled. Decreased physiologic
reactions to sexual stimulation are expected for the first 3 months and
emotional factors
g. Menstruation – if not breastfeeding, return of menstrual flow is expected within
8 weeks after delivery. If breastfeeding, menstrual return is expected in 3-4
months; in some women, no menstruation occurs during the entire lactation
period (IMPORTANT: Amenorrhea during lactation is no guarantee that the
woman will not become pregnant. She may be ovulating and the absence of
menstruation may be her body’s way of conserving fluids for lactation.
Implication: She should be protected against a subsequent pregnancy by
observing a method of contraception but not the pill.)
h. Postpartum check-up – should be done after the 6 th week postpartum to
assess involution.
3. Urinary changes
a. There is marked diuresis within 12 hours postpartum to eliminate excess
tissue fluid accumulation during pregnancy.
b. Some newly delivered mothers may complain of frequent urination in small
amounts; explain that it is due to urinary retention with overflow. Others, on
the other hand, may have difficulty voiding because of decreased abdominal
pressure or trauma to the trigone of the bladder. Voiding maybe initiated by
pouring warm and cold water alternately over the vulva, encouraging patient
to go to the comfort room and let her listen to the sound of running water. If
these measures fail, catheterization, done gently and aseptically, is the last
resort on doctor’s order. (If there is resistance to the catheter when it
reaches the internal sphincter, ask patient to breathe through the mouth
while rotating the catheter before moving it inward again.)
4. Gastrointestinal changes – delayed bowel evacuation postpartally may be due to:
a. Decrease muscle tone
b. Lack of food + enema during labor
c. Dehydration
d. Fear of pain from perineal tenderness due to episiotomy, lacerations or
hemorrhoids
5. Vital Signs
a. Temperature may increase because of the dehydrating effects of labor.
Implication: Any increase in body temperature during the first 24 hours
postpartum is not necessarily a sign of postpartum infection.
b. Bradycardia ( = heart rate of 50-70 per minute) is common for 6-8 days
postpartum.
c. There is no change in respiratory rate.
6. Weight – there is an immediate weight loss of 10-12 lbs representing the weights of
the fetus, placenta, amniotic fluid and blood. Further weight loss will occur during
the next days due to diaphoresis.
7. Psychologic phases
B. Provide emotional support – the psychological phases during the postpartum period are:
1.Taking-in phase – first 1-2 days postpartum when mother is passive and relies on
others to care for her and her newborn. She keeps on verbalizing her feelings
regarding the recent delivery for her to be able to integrate the experience into
herself.
2. Taking-hold phase – begins to initiate action and make decisions. Postpartum blues
( - an overwhelming feeling of sadness that cannot be accounted for) may be
observed. Could be due to hormonal changes, fatigue or feelings of inadequacy
in taking care of a new baby. Management: Explain that it is normal and that
crying is therapeutic, in fact.
2. Infection
a. Sources:
Endogenous (primary) sources – bacteria in the normal flora become virulent
when tissues are traumatized and general resistance is lowered
Exogenous sources – pathogens introduced from external sources.
Organism most frequently responsible for postpartum infections:
Anaerobic streptococci.
Common exogenous sources:
Hospital personnel
Excessive obstetric manipulations
Breaks in aseptic techniques – faulty hand washing, unsterile
equipments and supplies
Coitus in late pregnancy
Premature rupture of the membranes
b. General symptoms: malaise, anorexia, fever, chills and headache
c. General management: complete bed rest (CBR), proper nutrition, increased fluid
intake, analgesics, antipyretics and antibiotics, as ordered
d. Types of infection:
A. Infection of the perineum
Specific symptoms:
Pain, heat and feeling of pressure in the perineum
Inflammation of the suture line, with 1 or 2 stitches sloughed off
With or without elevated temperature
Specific management:
Doctor removes sutures to drain area and re-sutures
Hot Sitz bath or warm compress
B. Endometritis – inflammation/infection of the lining of the uterus
Specific symptoms:
Oxytocin
Fowler’s position to drain out lochia and prevent pooling of infected
discharge
C. Thrombophlebitis – infection of the lining of a blood vessel with formation
of clots; usually an extension of endometritis
Specific symptoms:
Pain, stiffness and redness in the affected part of the leg
Leg beings to swell below the lesion because venous circulation
has been blocked
Skin is stretched to a point to shiny whiteness, called milk leg –
phlegmasia alba dolens
Positive Homan’s Sign – pain in the calf when the foot is
dorsiflexed
Specific management:
Bed rest with affected leg elevated
Anticoagulants, e.g., Dicumarol or Heparin, to prevent further clot
formation or extension of a thrombus
Side effects: hematuria & increased lochia
Considerations:
Discontinue breastfeeding
Monitor prothrombin time
Always have Protamin sulfate or Vitamin at bedside to
counteract toxicity
Analgesics are given but NEVER Aspirin because it inhibits
prothrombin formation; since patient is already receiving an
anticoagulant, bleeding may occur
E. Motivate use of family planning methods – the success of the family planning
program depends to a great extent on the motivation of both husband and wife.
1. Physiological methods – the oral contraceptives.
a. Action: Suppresses the pituitary gland, thus inhibiting ovulation.
b. Types:
Combined – estrogen and progesterone in the same dosage each day
for 20 days, starting on the fifth day of the menstrual cycle, after which
it is discontinued and then resumed on the fifth day of the next
menstrual period.
Sequential – estrogen alone for 15 days, then estrogen and
progesterone for 5 days.
Mini-pill – taken continuously
c. Side effects – same complaints of pregnant women because of estrogen
and progesterone:
Nausea and vomiting
Headache and weight gain – both due to fluid retention because of
progesterone
Breast tenderness
Dizziness
Breakthrough bleeding/spotting between periods
Chloasma
d. Contraindications:
Breastfeeding
Certain diseases
Thromboembolism – because there is increased tendency towards
clotting in the presence of estrogen
Diabetes mellitus and liver disease – because estrogen tends to
interfere with carbohydrate metabolism
Migraine; epilepsy; varicosities
Cancer; renal disease; recent hepatitis
Women who smoke more than 2 packs of cigarettes per day
Strong family history of heart attack
2. Mechanical methods
a. Intrauterine device (IUD)
Specific action: Prevents implantation by setting up a non-specific cell
inflammatory reaction to the device
Inserted during a menstruation to ensure that the woman is not
pregnant; septic abortion can result if she is pregnant.
Side effects:
Increased menstrual flow
Spotting or uterine cramps during the first 2 weeks after insertion
Increased risk of infection
When pregnancy occurs with the device in place, it need not be
removed since it stays outside the membranes, and, therefore, will
not in any way harm the fetus
b. Diaphragm
Specific action: A circular rubber disc that fits over the cervix and forma
a barrier against the entrance of sperms
Is initially inserted by a doctor who determines the depth of the vagina
May be coated with a spermicidal jelly or cream for double protection
Maybe washed with soap and water after use
Sperms remain viable in the vagina for 6 hours, so the device
should be kept in place during such time, but should not stay for
more than 24 hours because stasis of semen can lead to
infection.
c. Condom
Specific action: Sperms are deposited in the tip of the rubber sheath
placed over an erect penis prior to coitus. Has the added potential of
lessening the change of contacting sexually-transmitted disease
(STDs)
Most common complaint of users: it interrupts the sexual act to apply
3. Chemical methods – are spermicidals (kill sperms). E.g., jellies, creams,
foaming tablets, suppositories
4. Biological method – Rhythm/Calental/Ogino-Knause Formula
a. Specific action: the couple abstains on days that the woman is fertile
b. Procedure
The woman charts her menstrual cycles for 12 continuous months in
order to determine the shortest and the longest cycles
The first fertile day is determined by subtracting “18” from the shortest
menstrual cycle; the last fertile day is determined by subtracting “11”
from the longest menstrual cycle.
E.g., if a woman’s shortest menstrual cycle is 26 days and her
longest is 32 days,
26 32
- 18 - 11
8 21
her fertile period would be from the 8 th to the 21st day of her
cycle, i.e., she should not have sexual intercourse during these days
5. Natural Family Planning (NFF) – periods abstinence:
a. Cervical mucus/Billing method
Basis: the flow of mucus from the cervix of the uterus
Method: a woman can discern her fertile and infertile days based on
her sensory and visual observations of the cervical mucus (when it
becomes thin and watery – spinnbarkeit), intercourse is avoided 4 days
prior to and 3 days after the spinnbarkeit
b. Basal Body Temperature (BBT)
Method: involves observing the temperature of the woman at rest, free
from any factor that may cause it to fluctuate (immediately upon
waking up, before doing anything else). As soon as the temperature
drops slightly and then increases (which means ovulation has taken
place), she counts 3-4 days, after which sexual intercourse may be
resumed.
c. Sympto-Thermal method – fertile and infertile days are determined after
having established an accurate record of the six immediately preceding
menstrual cycles and then watching out for BBT fluctuations.
6. Surgical methods
a. Tubal ligation – the Fallopian tubes are ligated in order to prevent passage
of sperms. Menstruation and ovulation continue
b. Vasectomy – small incision made into each side of the scrotum and the
vas deferens is and cut and tied, blocking passage of sperms. Sperm
production continues, only passage into the exterior is prevented.
(Sperms in the vas deferens at the time of surgery may remain viable for
as long as 6 months. Implication: couple should still observe a form of
contraception during this time to ensure protection against a subsequent
pregnancy.)
7. Social methods
a. Abstinence
b. Withdrawal or coitus interruptus
RISK PREGNANCY
I. BLEEDING IN PREGNANCY
Table 9. Outline of Classification
D. Details:
1. Preeclampsia
a. Underlying causes:
Insufficient production of blood and platelets
Generalized vasoconstriction and associated microangiopathy (-
disease of capillaries)
Abnormal retention of sodium and water by body tissues
b. Medical complications:
Cerebrovascular hemorrhage
Acute pulmonary edema
Acute renal failure
c. Types:
Mild preeclampsia
Signs and symptoms:
Sudden, excessive weight gain of 1-5 lbs per week (earliest sing
of preeclampsia) due to edema which is persistent and found in
the upper half of the body (e.g., inability to wear the wedding
ring)
Systolic BP of 140, or an increase of 30 mmHg, or more and a
diastolic of 90, or a rise of 15 mmHg or more, taken twice, 6
hours apart
Proteinuria of 0.5 gm/liter or more
Severe preeclampsia
Signs and symptoms
BP of 160/110 mmHg
Proteinuria of 5 gm/liter or more in 24 hours
Oliguria of 400 ml or less in 24 hours (normal urine output in 24
hours = 1560 ml)
Cerebral or visual disturbances
Pulmonary edema and cyanosis
Epigastric pain (considered an aura to the development of
convulsions)
Anarsavea/pitting edema; dependent type
Headache
Blurred vision
Oliguria
Epigastric pain (Aura)
2. Eclampsia – the main difference between preeclampsia and eclampsia is the
presence of convulsions in eclampsia.
a. Signs and symptoms – as in preeclampsia plus:
Increased BUN
Increased uric acid
Decreased CO2 combining power
E. Management:
1. Complete bed rest – sodium tends to be excreted at a more rapid rate if the
patient is at rest. Energy conservation is important in decreasing
metabolic rate to minimize demands for oxygen. Lowered oxygen
tension in toxemia is the result of vasoconstriction and decreased blood
flow that diminishes the amount of nutrients and oxygen in the cells. In
any condition wherein there is a possibility of convulsions, bed rest
should be in a darkened, non-stimulating environment with minimal
handling.
2. Diet:
a. For mile preeclampsia – high protein, high carbohydrate, moderate salt
restriction (no added table salt, (including “bagoong”, “patis” and “toyo”),
dired fish (e.g., “daing” and “tuyo”), canned goods, bottled drinks,
preserved foods and cold cuts)
b. For severe preeclampsia – highprotein, high carbohydrate and salt-poor (3
gms of salt per day)
3. Medications:
a. Diuretics – hourly urine output should be at least 20-30 ml (normally 50-60
ml per hour). E.g., chlorothiazide/Diuril.
Pharmacologic effect: decrease reabsorption of sodium and chloride at
the proximal tubules, thereby increasing renal excretion of sodium,
chloride and water, including potassium.
Side effects: fatigue and muscle weakness due to fluid and electrolyte
imbalance
Nursing care: closely monitor intake and output
b. Digitalis – if with heart failure
Pharmacologic action: Increase the force and contraction of the heart,
thereby decreasing heart rate. Should not be given, therefore, if heart
rate is below 60/minute. (Implication: take the heart rate before giving
the drug.)
c. Potassium supplements – any patient receiving diuretics are prone to
hypokalemia; if digitalis is given at the same time, hypokalemia increases
the sensitivity of the patient to the effects of digitalis. Potassium
supplements (e.g. banana) must be given to prevent cardiac arrhythmias.
d. Barbiturates – sedation by means of CNS depression
e. Analgesics: antihypertensives; antibiotics; anticonvulsants
f. Magnesium sulfate – drug of choice
Actions:
CNS depressant – lessens possibility of convulsions
Vasodilator – decreases the BP
Cathartic – it reduces edema by causing a shift of fluid from the
extracellular spaces into the intestines from where the
fluid can be excreted
Dosage: 10 Gms initially, either by slow IV push over 5-10 minutes, or
deep IM, 5 Gms/buttock; then IV drip of 1 Gm/hour (1
GM/100 ml D1 xxxxx) IF:
Deep tendon reflexes are present
Respiratory rate is at least 12 per minute
Urine output is at least 100 ml
Antidote for Magnesium sulfate toxicity: Calcium gluconate 10% IV to
maintain cardiac and vascular tone
Earliest sing of Magnesium sulfate toxicity: disappearance of the knee
jerk/patellar reflex
4. Methods of Delivery – preferably vaginal, but it not possible, CS will have to
be done
F. Prognosis: the danger of convulsions is present until 48 hours postpartum.
C. Compications:
1. Toxemia
2. Polyhydramnios
3. Anemia
4. Abruptic placenta
5. Prematurity
6. Postpartum hemorrhage
VIII. INDUCED LABOR – to bring out labor either by amniotomy or drugs (oxytocin or
prostaglandins) before the time when it would have occurred
spontaneously or because it does not occur spontaneously.
A. Indications:
1. Maternal
a. Toxemia
b. Placental accidents
c. Premature rupture of the BOW
2. Fetal
a. Diabetes – terminated about 37 weeks GA if indicated
b. Blood incompatibility with rising titer
c. Excessive size
d. Postmaturity
B. Prerequisites:
1. No CPD
2. Fetus is viable – survival is decreased if below 32 weeks CA
3. Single fetus is longitudinal lie and is engaged
4. Ripe cervix – fully or partially effaced; dilated at least 1 – 2 cm
C. Procedure
1. Oxytocin administration:
a. 10 IU of Pitocin in 1000 ml of D5W at a slow rate of 8 gtts/minute given
initially. If no fetal distress is observed in 30 minutes, infusion rate is
increased 16-20 drops per minute.
b. Amniotomy will be done when cervical dilatation reaches 4 cm. Check
FHR and quality of fluid after amniotomy.
c. Nursing care
Primary concern: monitor intensity of uterine contractions.
Remember: if uterine contractions are unduly sustained uterine rupture
can occur.
Monitor flow rate regularly
Turn off IV drip if with abnormalities in FHR or uterine contractions
Watch out for:
Hypertension – oxytocin is a vasoconstrictor
Antidiuresis leading to water intoxication
Headache and vomiting
Convulsions, coma, even death
2. Prostaglandin administration:
a. Route: Either oral or IV, never IM, because it causes tissue irritation
b. Effect: compared to oxytocin, the onset of contraction is slower.
IX. INFECTIONS
A. Syphilis
1. Cause: Treponema pallidum – a spirochete which enters the body during
coitus or through cuts and other breaks in the skin or mucous
membrane.
2. Treatment: 2.4 – 4.8 million units of Penicillin (if allergic, 30 – 40 gms. of
erythrocin) will usually prevent congenital syphilis in the newborn because
Penicillin readily crosses the placenta. If untreated, syphilis can cause
midtrimester abortion, CNS lesions in the newborn or even death.
3. The newborn with congenital syphilis
a. Signs and symptoms:
Jaundice at 2 weeks of life – first signs of the disease
Anemia and hepatosplonomegaly
“snuffles” (persistent rhinorrhea); coppery rashes on plams and soles;
mucous patches; condylomas; pseudoparalysis due to bone
inflammation
If untreated, can progress on to deformed bones, teeth, nose, joints and
CNS syphilis
b. Management: Penicillin IM for 10 days or one long-acting Penicillin
(Penadur LA)
B. Rubella/German Measles
1. Incidence:
a. Mother – the earlier the mother contacted the disease, the greater the
likelihood that the baby will be affected. The rubella virus slows down
division of infected cells during organogenesis.
b. Newborn – can carry and transmit the virus for as long as 12-24 months
after birth
2. Signs and symptoms of Congenital Rubella Syndrome:
a. Low birth weight; jaundice; petechiae; anemia; thrombocytopenia;
hepatosplenomegaly
b. Classes sequelae;
Eyes: choricretinitis, cataract, glaucoma
Heart: Patent Ductus arteriosus, stenosis, coarctations
Xxxx nerve deafness
Dental and facial clefts
THE NEONATES
II. Maintain appropriate body temperature. Chilling will increase the body’s need for
oxygen. The newborn suffers large losses of heat (cold stress) because he is wet at
birth, the delivery room is cold, he does not have enough adipose tissues and does not
know how to shiver. Effect of cold stress:
Metabolic acidosis – one of the ways by which heat is produced in the newborn is
by increasing metabolism. When this occurs, fatty acids accumulate because of
the breakdown of brown fat (seen only in newborns).
Hypoglycemia – due to the use of glucose stored as glycogen
A. Dry the newborn immediately
B. Wrap him warmly
C. Put him under a droplight
SIGN 0 1 2
1. Interpretation of results:
a. 0 – 3 - the baby is in serious danger and needs immediate
resuscitation
b. 4 – 6 - condition is guarded and may need more extensive clearing of
the airway
c. 7 – 10 - baby is in the best possible health
1. Sole creases Anterior transverse Occasional creases, Sole covered with creases
crease only anterior two-thirds
2. Breast nodule diameter 2 mm 4 mm 7 mm
3. Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
IV. Proper Identification – of the newborn must be done in the delivery room before
bringing to the Nursery.
Footprints are said to be the best way which identify newborns.
V. Nursery Care
A. Check identification band
B. Take anthropometric measurements:
1. Length – average: 50 cm (20 in.) = 19 - 21 ½ inches (47.5-53.75 cm.)
2. Head circumference = 33 – 35 cm.
3. Chest circumference = 31 – 33 cm.
4. Abdominal circumference = 31 – 33 cm.
C. Take the temperature – at birth is 37.2 oC or 99oF, but because of evaporation from
the moist skin and the cool delivery room, will stabilize in 8 hours time and must be
maintained at 35.5oC – 36.5oC (97oF – 99oF) so as to prevent hypoglycemia and
acidosis due to hypothermia. Axillary and rectal temperatures are approximately
the same immediately following birth but the rectal route is preferred in order to
check patency of the anus.
D. Specific nursing actions:
1. Give initial oil bath to cleanse the baby of blood, mucus and vernix
2. Dress the umbilical cord. Inspect for the presence of 2 arteries and 1 vein.
Suspect a congenital anomaly if blood vessels are not complete; a more
thorough physical assessment is indicated and closer observation in an ICU
is done.
3. Crede’s prophylaxis – prophylactic treatment of the newborn’s eyes against
gonorrheal conjunctivitis (ophthalmic neonatorum) which the baby acquires
as he passes through the birth canal of his mother who has untreated
gonorrhea:
a. Wipe and face dry.
b. Shade the eyes from light and open one eye at a time by exerting gentle
pressure on the upper and lower lids.
c. 2 drops of 1% silver nitrate are instilled one at a time into the lower
conjunctival sac. (Be careful not to drop on the cheeks because parents
may worry about the stain)
d. Wash silver nitrate away with sterile NSS after 1 minute to prevent
chemical conjunctivitis (inflammation, edema, purulent discharge)
e. Penicillin/chloromycetin/terramycin ophthalmic ointment may be used
since it does not irritate the eyes (although the baby may develop
sensitivity at an early age). Apply from the inner to the outer canthus of
the eye.
4. Vitamin K administration
a. Rationale: Vitamin K facilitates production of the clotting factor, thus
preventing bleeding. But Vitamin K is synthesized in the
presence of normal bacterial flora in the intestines. Since
the newborn’s intestines are still relatively sterile, therefore,
they will not be able to synthesize Vitamin K; that is why
synthetic Vitamin K is given to prevent hemorrhage.)
b. Method: 1 mg. Aquamephyton (generic name is phytonadione) is injected
IM into the lateral anterior thigh (vastus lateralis). In children
below 12 months of age how have not yet learned how to walk,
this is the preferred site of injection because gluteal muscles
are not yet fully developed.
5. Weight-taking
a. Average birth weight = 6 ½ - 7.5 lbs = 3 – 3.4 kgs = 300 – 3400 gms.
b. Arbitrary lower limit – below which the newborn is said to be of low birth
weight: 5.5 lbs = 2.5 kgs = 2500 gms.
c. Ideal procedure
Weigh the clothes first
Put on the baby’s clothes
Weigh the baby with his clothes on
Subtract the weight of the clothes from the total weight of the
baby and his clothes
d. Physiologic weight loss of 5 – 10% of birth weight (6-10 oz) during the first
10 days of life because the newborn:
Is no longer under the influence of maternal hormones
Voids and passes out stools
Has limited intake
Has beginning difficulty establishing sucking
6. Feeding
a. Initial feeding – is a test feeding consisting of an ounce of sterile water
(glucose water has been found to irritating to the lungs if aspirated) is
given to find if the newborn can swallow without aspirating.
b. Subsequent feedings – preferably given by demand
E. Physical Assessment
1. Pulse – normally irregular and 120-140 per minute. Apical pulse (stethoscope
below the left nipple) is recommended since radial pulses are not
ordinarily palpable (if prominent, in fact, may b ea sign of congenital
heart anomaly).
2. Respirations – are gentle, quiet, rapid but shallow; normally 30-60 per minute.
Largely diaphragmatic and abdominal (watch for the rise and fall of the
chest and abdomen).
3. Blood pressure – not routinely measured in newborns unless coarctation of
the aorta is suspected.
a. Normal values:
At birth – 80/46 mm Hg
After 15 days – 100/50 mm Hg
b. Size of cuff in children: Must not be more than 2/3 the size of the
extremity (will result in false low BP) nor less than ½ the length of the
extremity (will result in false high BP).
c. Procedure – flush method:
Cuff is applied to an extremity
Extremity is elevated and an elastic bandage is wrapped around the
distal portion of the extremity
Slowly inflate the cuff up to 100 mm Hg, then remove the bandage
(extremity is expectedly pale)
As soon as the extremity turns pink (flushes), read the manometer.
Only one reading can be obtained, the average between the diastolic
and the systolic pressures, called flush pressure (therefore, is normally
60).
4. Skin
a. Color – normally ruddy because of the increased concentration of RBCs
and the decreased amount of subcutaneous fat
Acrocynosis – body pink, extremities blue. Normal during the first 24-
48 hours of life.
Generalized mottling is common due to an immature circulatory system
Pallor – due to anemia which results from excessive blood loss when
cord is cut, inadequate blood flow from cord to infant at birth,
inadequate iron stores because of poor maternal nutrition.
May also be due to blood incompatibility.
Gray color – indicated infection
Jaundice – yellowish discoloration of the skin sclerae:
Cause: Inability of the newborn to conjugate bilirubin.
Normal Values
Total bilirubin = 15 mg%
Direct bilirubin = 1.7
Indirect bilirubin = 13.3
Most accurate method of assessing presence of jaundice: Use
natural light and blanch skin on the chest or tip of the nose
Physiologic jaundice – from the 2nd to the 7th day of life.
Breastfed babies, however, have longer physiologic jaundice
because human milk has pregnanediol which depresses the
action of glucose xxxxxxxxxxxxxxx (the enzyme responsible for
converting indirect bilirubin to direct bilirubin)
Harlequin Sign – because of immaturity of circulation, an infant
who ahs been lying on his side will appear
red on the dependent side and pale on the
upper side.
Mongolian spots – slate-gray patches seen across the
sacrum/buttocks and consist of collections
of pigment cells (melanocytes). Disappear
by school age. Seen only among
Southern European, Asian and African
children.
Lanugo – fine, downy hair that covers the shoulders, back and
upper arms.
Desquamation – drying of newborn’s skin
Cephalhematoma – due to increased intravascular pressure
during delivery
Milia – unopened sebaceous glands found on the nose, chin and
cheeks; disappear spontaneously by 2-4 weeks.
5. Head – largest part of the infant’s body (1/4 of his total length).
a. Forehead is large and prominent
b. Chin is receding and quivers when startled or crying
c. Fontanelles are neither sunken (a sign of dehydration) nor bulging (a sign
of increased intracranial pressure)
d. Suture lines should neither be separated nor fontanelles prematurely
closed (-craniosynostosis; leads to mental retardation)
e. Craniotabes – localized softening of the cranial bones can be indented by
pressure of a finger. Corrects itself without treatment after some months.
More common among first-borns because of early lightening.
Period of absorption (most On or about the third day Takes several weeks
significant differences)
6. Eyes
a. Method of assessment: Put infant on upright position
b. Characteristics:
Cry tearlessly during first 2 months because of immature lacrimal ducts
Cornea should be round and adult-sized
Pupils should be round, not key-holed (- coloboma).
7. Ears – level of top part of external (should be in line with outer canthus of the
eye. If set lower, maybe a sign of kidney malfunction or Down’s
syndrome
8. Nose – may appear large for the face; there should be no septal deviation
9. Mouth
a. Should open evenly when crying; if not, suspect cranial nerve injury
b. Tongue appears large
c. Palate should be intact; no break on the lips
d. Epstein’s pearls – 1 or 2 small, round, glistening cysts seen on the palate;
due to extra load of calcium while in utero
e. A tooth may be seen; if loose, should be extracted to prevent aspiration
when feeding.
f. Oral thrush – white or gray patches on the tongue and side of the cheeks
due to Candida albicans acquired during passage of the baby through
the birth canal of the mother with untreated Moniliasis; also known as
oral moniliasis.
10. Neck
a. Thyroid gland is not palpable
b. Appears soft and chubby and creased with skin folds
c. Head should rotate freely on the neck and flex forward and back
11. Chest – as large as, or smaller than, the head:
a. Should be symmetrical
b. Breasts maybe engorged, a result of the influence of maternal hormones
c. Witch’s milk – thin, watery fluid also due to maternal hormones
12. Abdomen:
a. Liver, spleen and kidneys are palpable at birth. Liver is about 1-2 cm
below the right costal margin
b. Normally dome-shaped; if scaphoid, suspect Diaphragmatic Hernia
13. Anogenital area
a. Take note of the time meconium is first passed (it should be within the first
24 hours of life)
b. Female genitalia: may have swollen labia and drops of blood due to
maternal hormones
c. Male genitalia:
Scrotum maybe edematous – also due to maternal hormones
Foreskin should be retracted to test for phimosis (-tight foreskin)
Testes should be present; if not descended, the condition is called
crypto-orchidism (repair of undescended testes is called orchidopexy).
Circumcision – maybe done prior to discharge from the nursery,
preferably by the end of the first week.
Procedure:
Vitamin E injected IM
Infant is restrained; penis is cleansed with soap and water
Yellen clamp is used
Petrolatum gauze dressing is applied to prevent adherence of
circumcised site to the diaper while applying pressure to prevent
bleeding
Nursing care:
Check hourly for bleeding (most common complication) during
the first day. If small amount of bright red blood is observed,
apply gentle pressure to the area with a sterile gauze pad
Do not attempt to remove exudate which persists for 2-3 days.
Just wash with warm water
Diaper must be pinned loosely during first 2-3 days when the
base of the penis is tender
14. Back – on prone, appears flat (curves start to form only when sitting or
waling has been achieved).
15. Extremities
a. Arms and legs are short; hands are plump and clenched into fists
b. Should move symmetrically
c. Abnormalities:
Erb-Duchenne paralysis/Brachial plexus injury
Causes:
Lateral traction exerted on head and neck during delivery of the
shoulder in vertex presentation
Excessive traction on the shoulders during breech extraction,
especially when the arms are extended over the head
Signs and symptoms:
Inability to abduct arm from the shoulder, rotate arm externally or
supinate forearm
Absent Moro reflex on affected arm
Some sensory impairment in the outer aspect of affected arm
Management: Abduct the affected arm in external rotation position
with the elbow flexed
Congenital hip dislocation/dysplasia
Signs and symptoms:
Assist in replacing head of the femur into the acetabulum of the
hip bone by using 3 diapers instead of one, or by putting a pillow
between the thighs to maintain abduction of the thighs and
flexion of the hip and knee joints
Infant preferably carried astride mother’s hip
Hip spica cast is applied at a later age, before the infant starts to
walk. Cast extends from the waistline to below the knee of the
affected leg and above the knee of the unaffected leg. If
treatment is delayed (after the baby has already learned how to
walk), the child will become xxxxxxxxx walk with xxxxxxxxxxxxx
at a later age.
F. Systemic Evaluation
1. Cardiovascular System
a. Major Differences in fetal circulation:
Exchange of oxygen and carbon dioxide takes place in the placenta, not
in the fetal lungs
Because little blood goes to the fetal lungs, pressure in the left side of the
fetal heart is less than the pressure in the right side of the fetal heart.
Presence of fetal accessory structures:
Foramen ovale – bypasses the pulmonary circulatory system since it is
the opening between the right and left atria
Ductus arteriosus – communication between the pulmonary artery and
the aorta
Ductus venosus – communication which bypasses the liver
Umbilical vein – carries the most highly oxygenated blood
Umbilical arteries – carry deoxygenated blood
b. Neonatal/adult circulation – as soon as breathing has been initiated,
oxygenation now takes place in the newborn’s lungs. The change from fetal
to neonatal circulation is, therefore, associated with lung expansion, causing
pressure in the left side of the newborn’s heart to become higher compared
to pressure in the right side of the newborn’s heart.
Increased pressure on the left side of the newborn’s heart results in:
Closure of the foramen ovale
Change of the ductus arteriosus into a mere ligament (ligamentum
arteriosum)
The decreased pressure on the right side of the newborn’s heart causes
the ductus venosus to become a mere ligament (ligamentum venosum)
Since no more blood goes through the umbilical vein and arteries, these
blood vessels atrophy and degenerate.
c. Blood values – are all high in their newborn period as a response to the
pulmonary circulation:
Red blood cells – 6 millon/ml3
Hemoglobin – 17-18 Gms %
Hematocrit – 52%
White blood cells – 15,000 – 45,000 per ml 3. A high WBC count during
the newborn period, therefore, is not a sign of infection; with or without
infection all newborns have high WBC count.
2. Gastrointestinal tract – differences in stools:
a. Colostrum – xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx formed from mucus, vernix,
lanugo, hormones and carbohydrates that accumulated
while in utero
b. Transitional – on the 2nd to the 10th day of life in response to the feeding
pattern; are xxxx, green and loose, resembling diarrhea to
the untrained eye
c. Breastfed – golden yellow, xxxxx, more frequent (3-4 times/day) and sweet-
smelling because breast is high in lactic acid which reduces
the amount of putrefactive organisms
d. Bottlefed – pale yellow, firm, less frequent (2-3 times/day) and with a more
noticeable odor
3. Urinary system – newborns should avoid within the first 24 hours of life
a. Female newborn – form a strong stream when voiding
b. Male newborn – form a small produced arc when voiding. If not, suspect a
defect in the urethral meatus:
Epispadia – urethral meatus located in the ventral (under) surface of the
penis
Hypospadia – urethral opening located in the dorsal (above) surface of
the penis
Management:
Inspect for cryptoorchidism often found associated with
hypo-/epispadias
Meatotomy is done to establish better urinary function
When the child is older (12-18 months), adherent chordae (-fibrous
bands that cause the penis to curve downward) may be released
surgically. If repair will be extensive, surgery might be delayed until
3-4 years old.
Child should not be circumcised because at the time of repair, the
surgeon may wish to use a portion of the foreskin
Surgical correction is done before school age so that the child
appears normal to his schoolmates
4. Autoimmune system
a. Type of immunity transferred from mother to newborn: passive natural
immunity
b. Newborns have antibodies from the mother against poliomyelitis, diphtheria,
tetanus, pertussis, rubella and measles (present in the infant for one year).
But little or no immunity against chickenpox (that is why chickenpox is often
fatal in the newborn).
c. Newborns have difficulty forming antibodies until 2 months of age (that is why
immunizations are started at 2 months).
5. Neuromuscular system
a. Blink reflex – rapid eyelid closure when strong light is shone; always present
b. Feeding reflexes:
Rooting reflex – head will turn to the direction where cheek is stroked
near the corner of the mouth; will help infant find food; disappears by 6
weeks of age when infant is already capable of seeing things past the
visual midline.
Sucking reflex – anything placed between the lips will be sucked;
disappears by 6 months. IMPORTANT: Sucking reflex disappears
immediately if not stimulated regularly. IMPLICATION: Any infant who
will be put on NPO should be given a pacifier not only for psychological
reasons, but also to prevent premature disappearance of the sucking
reflex.
Extrusion reflex – anything placed on the anterior portion of the tongue
will be spit out; disappears by 4 months of age when infant is about
ready for semi-solid foods.
Swallowing reflex – anything place at the back of the tongue will be
swallowed and will never disappear.
c. Tonic neck reflex – (TNR)/Fencing reflex/boxer reflex – when on his back, the
infant’s arm and leg are extended on the side where the head is turned, while
the arm and the leg on the opposite side are flexed; disappears by 2-3
months
d. Babinski reflex – when side of the sole is stroked with a “j” from heel upward,
the infant will fan out his toes; starts to disappear by 3 months of age. (If the
adult’s sole is stroked, the adult will curve in his toes).
e. Landau reflex – when on prone, the newborn should demonstrate some
muscle tone; a test of spinal cord integrity
f. Palmar or plantar grasp/step-in-place reflexes – accessory reflexes.
g. Moro reflex – singular most important reflex indicative of neurological status.
If he bassinet is jarred or the infant’s head is allowed to drop backward in
supine position (change infant’s equilibrium), the infant will abduct and then
adduct his arms. Disappears by 4-5 months.
6. Senses – all are functional at birth:
a. Sight – all newborns can see at birth, although they cannot see objects past
the visual midline (not until 6-8 weeks). The visual field is 20-22 cm
or 9 inches
b. Hearing – as soon as amniotic fluid has been absorbed, the newborn can
already hear
c. Taste – as soon as secretions have been suctioned, newborns can already
taste
d. Smell – as soon as the nose has been cleared of mucous and fluid, newborns
can smell
e. Touch – the most developed of all the senses
G. Discharge Instructions
1. Bathing – maybe given anytime convenient for the parents as long as it is not within
30 minutes after a feeding because the increased handling during bathing can
cause regurgitation. Sponge baths are done until the cord falls off (7 th-14th day).
2. Cord care
a. Fold down diapers so that cord does not get wet during voiding
b. Dab rubbing alcohol (10%) once or twice a day
c. Small, pink granulating area may be clean on the day of the cord falls off. If
remains moist for a week, advise mother to bring baby to the doctor’s clinic
where cautery with silver nitrate stick will be done to speed healing.
3. Nutrition
a. Recommended Daily Allowances
Calories – 120 cal/kg body weight
(KBW) = 50-55 cal/lb body weight
= more or less 3000 cal/day
Proteins = 96 Gms/KBW/day
Fluids = 16-20 cc/KBW = 2.5 – 3 oz per lb body weight = more or less 20
oz/day
Vitamins – Vitamins A, C and D are recommended for both bottlefed and
breastfed babies during the entire first year of life.
Protein 8% 20%
Fats 50% 50%
Carbohydrates 42% 30%
Sodium 7 mEq/liter 25 mEq/liter
Potassium 14 mEq/liter 36 mEq/liter
Calcium 12 mEq/liter 61 mEq/liter
Phosphorus 9 mEq/liter 53 mEq/liter
Chloride 12 mEq/liter 34 mEq/liter
RISK NEWBORNS
B. Characteristics
1. Have underdeveloped subcutaneous tissues and less fat to act as insulation. Are
thin-skinned. This is the reason why rapid drying and warming inside incubators
are important. In incubator care:
a. Temperature = 92o – 94oF (33.3o – 34.4oC)
b. Humidity = 55 – 65%
c. Frequent positioning on the right side will favor closure of the foramen ovale
because of the increased pressure of the left ventricle
2. Are poikilothermic (- easily take on the temperature of the environment).
Temperature stabilizes at a lower rate: 35 o – 36oC. Take the axillary, not the rectal
temperature before crying will mean increased energy expenditure. (Important: A
special consideration in the care of premature babies is conservation of energy for
growth and development.)
3. Physiologic weight loss is exaggerated.
4. General activity is more feeble and weak; they often assume frog-like position;
extremities have less muscle tone (scarf sign – elbow passes the midline of the
body; square window wrist – wrist at a 90o angle).
5. CNS centers for respiration are underdeveloped, which results in irregular breathing
with short periods of apnea. Oxygen administered should never be more than 40%
because it can lead to retrolental fibroplasias (- an overgrowth of retinal blood
vessels causing blindness).
6. Nutritional requirements – are high in order to maintain rapid growth appropriate for
the developmental stage. Birth weight, kidney and GIT functioning should be
considered in determining nutritional requirements of the preemies.
a. Method of feeding – basically by NGT.
Rationale
Prematures often have ineffective sucking which is not coordinated
with swallowing and, therefore, may aspirate.
Minimal handling is necessary in order to conserve
energy.
Procedure
Determine the distance to which the NGT is to be inserted by
measuring from the ear lobe to the nose to the distal end of the
sternum
Mummify (restrain) the baby as the NGT is being
inserted
Check location after NGT has been inserted:
Submerge tip of the NGT in a glass of water; if bubbles appear, it
is inside the lungs
Inject 5 cc. of air, then auscultate. If no sound is heard as air is
injected, it means that the NGT is not in the stomach but in the
lungs
Aspirate contents; if acids are aspirated, the NGT is in the stomach
Determine amount of residual milk or undigested milk and subtract the
same amount from the next feeding because this means that the baby
is not able to digest all the milk that is given to him. Be sure to put
back the residual milk since it contains acids and the baby can develop
metabolic alkalosis if not give back to the baby.
Keep the NGT always closed to avoid abdominal
distention
Fill syringe with formula before opening NGT; let formula flow by
gravity
Feed with sterile water after the formula in order to prevent clogging
the NGT.
C. Special Problems
1. Hyperbilirubiremia – because of immaturity of the liver, kernicterus (-staining of
brain cells with bilirubin, causing brain damage or even death) appears to occur at
a lower bilirubin level. Management: phototherapy – photooxidation by the use of
artificial blue light in order to convert bilirubin into an excretable form. Nursing
responsibilities in phototherapy care:
a. Expose all areas of the body to light by turning the infant every 2 hours
b. Cover eyes and genitalia
c. Give plenty of fluids to prevent dehydration
d. Check for loose stools and increased body temperature
A. Classic signs – “old man faces”; evidence intrauterine weight loss, dehydration and
chronic hypoxia.
1. Long and thin
2. Cracked skin which is loose, wrinkled and stained greenish-yellow, with no vernix
nor lanugo
3. Long nails; firm skull
4. Wide-eyed alertness of a one month old baby
B. Management:
1. Monitor vital signs
2. IV, as ordered
C. Outlook: reasonable
IV. Chalasia
A. Pathophysiology: On the 3 rd to the 10th day of life, the cardiac sphincter muscles fail to
function, causing it to be relaxed and constantly patent.
B. Characteristics: Unknown cause; self-limiting – disappears spontaneously within 3
months
C. Signs and symptoms
1. Prolonged, repeated non-projectile vomiting which is more pronounced when patient
is lying flat on his back
2. Often hungry after each vomiting episode
3. Aspiration may occur
4. Pressure on abdomen causes reflux of stomach contents into the esophagus
D. Management:
1. Thickened feedings (formula + cereals) – because they are less easily vomited
2. Put on upright position for 30 minutes after every feeding
V. Imperforate Anus
A. Unknown etiology – arrest in embryologic development at 8 weeks of intrauterine life
B. Types
C. Signs and symptoms
1. Normal opening
2. No meconium
3. Green-tinged urine – due to fistula
4. Inability to insert rectal thermometer
5. Abdominal distention
D. Diagnosis: xxxxxxxxxxx xxxxx method – infant is held upside down while abdomen is
filmed to determine distance from rectum to anal dimple
E. Management:
1. NPO; IV xxxxx gastric xxxxxxxxxxx
2. Temporary colostomy – if poor surgical risk (very young baby, malnourished; high
agenetic or stretic type
3. Surgery:
a. Anoplasty
b. Abdominoperineal pull-through
4. Postoperative care:
a. Expose perineum to air by putting infant on supine with legs suspended
straight up or on prone position
b. Check bowel sounds frequently
c. NGT for gastric decompression
d. Change position from side to side to decrease tension on suture line
e. Oral feedings resumed 1-2 days postop, when peristalsis has resumed (fluids
are retained; stools/flatus passed)
VI. Spina Bidifa – congenital problem in which there is a defective closure of the spinal
column.
A. Classification
1. Occulta – posterior laminae are usually affected, with no protrusion of spinal
contents. Skin over the defect may reveal a dimple, a small fatty mass or a tuft
of hair.
2. xxxxxxx
a. Meningocele
b. Myelomeningocele – congenital failure of the arches of one or more vertebrae
to unite at the center of the back; so that the bony wall normally surrounding
the spinal canal at that place is missing. There is external protrusion,
through a transparent sac, containing spinal fluid meninges, spinal cord
and/or nerve roots. It is the most severe of the spinal deformities.
c. Encephalocele- a cranial meningocele or meningomyelocele occurring at
occipital area of the skull but may occur as a nasal or nasopharyngeal defect.
B. Associated clinical problems – depend on the location; all body parts below the session
are affected
1. Motor function:
a. Feet maybe deformed
b. Joints of ankles, knees or hips may be immobile
c. Variable degrees of weakness in the lower extremities
d. Spontaneous and induced movements are decreased or absent
2. Sensory function:
a. Sensations usually absent below the level of the defect
b. Ulcerations of the skin are common
3. Impaired functioning of the autonomic nervous system:
a. Skin is dry and cool
b. Sweating ability is impaired
4. Urinary and bowel problem:
a. Inefficient bladder causes constant urinary dribbling
b. Stasis of urine causes UTI
c. Possible renal destruction
d. Fecal incontinence or retention due to poor innervation of the anal sphincter
and bowel musculature
5. Hydrocephalus – occurs in 65% of children; usually develops within the first 6 weeks
of life.
D. Surgical correction
1. Early excision of the sac if it is small and then primary closure is done
2. If base of the defect is too large for primary closure, conservative treatment is
carried out first while waiting for epithelization to take place and then closure is
done at a later time.
E. Postoperative care
1. Keep on prone position
2. Monitor urine output – bladder injury is a high possibility in operations involving
the spinal column
3. Measure head circumference daily
4. Monitor movement of lower extremities
F. Complications
1. Meningitis
2. Severe neurologic deficits
3. Hydrocephalus
a. Types:
Noncommunicating – blockage within the ventricles which prevents CSF
from entering the subarachnoid space
Communication – obstruction in the subarachnoid cistern at the base of
the brain and/or within the subarachnoid space
b. Management
1.5 – 2 Gms. Mannitol 20%/KBW over 10 -15 minutes – since Mannitol is
a diuretic, an indwelling, catheter should be inserted for accurate
recording of intake and output
Ventriculo-peritoneal/ventriculo-atrial shunt – to bring the CSF to an area
from where it can be excreted from the body. After the procedure, the
child should be positioned on the side where the shunt is to prevent
sudden decrease in intracranial pressure.