BACHELOR OF SCIENCE IN NURSING

OUTCOME BASED CLINICAL LEARNING 1

COURSE MODULE COURSE UNIT WEEK
CM1 CU5 5

 Read course and unit objectives

 Read study guide prior to class attendance
 Read required learning resources; refer to unit terminologies for jargons
 Proactively participate in classroom discussions
 Participate in weekly discussion board (Canvas)
 Answer and submit course unit tasks.

Saunders Q & A Review for the NCLEX-RN Examination, 8th edition

Hinkle, Janice L. (2014)Brunner & Suddarth’s text book of Medical Surgical Nursing, 13 th. Philadelphia:
LippincottWilliams & Wilkins.617.0231 H592014

At the end of the course unit (CM), learners will be able to:
Cognitive:
1. Identify what is pregnancy and antenatal care
a. Prenatal visit
b. Signs of Pregnancy
c. Physiologic changes
d. Nutritional Requirement
e. Pregnancy Discomforts
 2. Computation of EDD/ EDC
a. Naegel’s Rule
b. AOG
c. Mc Donalds Methods
3. To determine the importance of Leopold”s maneuver
4. Labor and delivery:
a. Premonitory signs of Labor
b. Factor affecting Labor
c. Mechanism of Labor
d. Stages of Labor
5. Post natal care
a. Emotional and behavioral changes
Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.
Psychomotor:
1. Participate actively during class discussions and group activities
2. Express opinion and thoughts in front of the class

Introduction

Pregnancy
 Is a normal physiologic process by which POC are retained inside the uterus for implantation
and development.
 Lasts for 9 months – 38 to 42 wks – 266 to 280 days…

Physiologic Adaptation to Pregnancy

Cardiovascular Changes
 Blood Volume increase
 Plasma increase
 RBC increase
 HR and Cardiac Output Increase; BP increase
Muscoloskeletal Changes
 Lordosis
 Increase backache
 Diastasis Recti Abdominis
abnormal separation of the two sides of rectus abdominus muscle

Integumentary Changes
 Integumentary changes are due to increase production of melanin and stretching of the skin
 Chloasma
 Areolar changes
 Linea Negra
 Striae Gravidarum

Respiratory Changes
 Vasoconstriction of the upper respiratory lining
 Nasal congestion leading to voice changes
 Increase in thoracic diameter
 DOB and SOB

Gastrointestinal Changes
 Delayed gastric emptying time
 Slowed peristalsis
 Nausea and vomiting

Reproductive Changes
 Uterus
 Cervix and Ovaries
 Vagina and Perineum
 Breasts

Signs of Pregnancy

Presumptive Signs (Subjective)

1. Amenorrhea (cessation of menstruation)

2. Nausea and vomiting
3. Urinary frequency
4. Fatigue
5. Breast changes
6. Weight change
7. Skin changes
8. Vaginal changes including leukorrhea
9. Quickening
Probable Signs (Objective)

1. Chadwick’s sign
2. Hegar’s sign
3. Goodell’s sign
4. Sonographic evidence of gestational sac
5. Ballottement
6. Braxton Hick’s contraction
7. Positive pregnancy test
8. Palpation of fetal outline

Positive Signs (Health Care Provider)

 Sonographic evidence of fetal outline
 Fetal heart audible by Doppler ultrasound
 Palpation of fetal movement

Prenatal Care

Prenatal Visits
 Time frame
1. First visit: may be made as soon as woman suspects she is pregnant; frequently after
first missed period.
2. Subsequent visit: Every month until the 8th month for high risk patients.Or at least 4x
for the entire pregnancy.
Conduct of Initial Prenatal Visit:
1. Extensive collection of data
 Menstrual history: menarche, regularity, frequency and duration of flow, last period.
 Obstetrical history: all pregnancy, outcome, complications, contraceptive use, sexual
history, GPTPALM Scoring
G (Gravida) - number of pregnancies
P (Para) - total number of deliveries >20 weeks AOG
T (Term) - total number of infants born at term or 37 weeks or more
P (Preterm) - total number of infants born before 37 weeks
A (Abortion) - total number of spontaneous or induced abortions below 20 wks gestation
L (Living) - total number of children currently living
M (Multiple) - total number of multiple pregnancies
 Medical history: include past illnesses, surgeries; current use of medication
 Family history/ psychosocial data: Information about the father-to-be may also be
significant
 Current concerns
Expected Date of Delivery (EDD/EDC)

Naegele’s Rule
 calculation of expected date of confinement (EDC). January - March
-3 months + 7 days
ex: January 2, 2017 (1st day of last menstruation)
1 2 17
+9 +7
10 9 17 (Oct. 09, 2017)
Age Of Gestation (AOG)

 McDonald’s method
Fundic ht in cm x 2 / 7
= AOG in months
Fundic ht in cm x 8/ 7
= AOG in weeks
Ex. 21 cm x 2 / 7 = 6 months
21 cm x 8/7 = 24 weeks

 Bartholomew’s method
Estimated AOG by the relative position of the uterus in the abdominal cavity
3rd mo. the fundus is palpable above symphysis pubis
th
5 mo. the fundus is palpable at the level of umbilicus
9th mo. the fundus is below xiphoid process

 Based on the LMP

Sample:
LMP – December 4, 2016
December – 27
January - 31
February - 28
March - 31
April - 28
145 days
145/ 7 = 20 weeks & 5 days 20/ 4 = 5 months

Prenatal Visit:
2. Complete physical examination, including internal gynecologic exam and bimanual exam
3. Laboratory exams (CBC, urinalysis, pap test, blood type and Rh, rubella titer, testing for
sexually transmitted diseases (STD), other test as indicated (e.g. TB test, hepatitis viral studies,
EKG, etc)

Conduct of subsequent visit

 1. Continue collection of data, especially weight, blood pressure, urine screening for glucose
and protein, evaluation of fetal development through auscultation of fetal heart rate (FHR) and
palpitation of fetal outline, measurement of fundal height as correlation for appropriate progress
of pregnancy.
2. Prepare for necessary testing.
 Have client void (clean catch)
 Collect baseline data on vital signs
 Collect specimen
 Monitor client and fetus after procedure
 Provide support to client
 Document as needed
Tetanus Toxoid Immunization

Schedule of Immunization
 1st dose – anytime during pregnancy
 2nd dose – a month after
 3rd dose – after another 6 months
 4th & 5th – every year

Leopold's maneuver

 Abdominal Examination – is preferably performed after 24 weeks gestation when the fetal
outline can be palpated
 Preparation:
○ Cardinal Rule – Empty the bladder first.
○ Position the woman in a dorsal recumbent position, place a pillow ender the head for
comfort.
○ Maintain privacy.
○ Explain the procedure to gain patient’s cooperation.
○ Warm hands by rubbing them together before placing them over the woman’s abdomen.
○ Use palms not fingers for palpation.
 Maneuver Purpose Procedure Findings
First Maneuver: To determine fetal Using both hands If the fetus is
Fundal Grip part lying in the feel for the fetal cephalic:
fundus part lying in the Head – round,
fundus smooth with
To determine transverse groove
Presentation of the neck.
If the fetus is
breech:
Buttocks – soft and
angular.

Fourth Maneuver: To determine Facing foot part of If descended

Pelvic Grip degree of flexion of the women, palpate deeply, only a
fetal head. fetal head pressing small portion of
To determine downward about 2 the head will be
attitude or habitus inches abopve the palpated. If
inguinal ligament. cephalic, brow of
Use both hands the baby is on the
same side of the
fetal part, the head
is flexed.
If the head is
extended, brow is
on the same side of
the fetal back.
Pregnancy discomforts

 Urinary frequency
 Void as necessary
 Decrease fluids before bed
 Avoid caffeine
 Perform Kegel exercises
 Report signs of infection
 Fatigue
 Try to get a full night’s sleep
 Schedule a daily rest time
 Maintain good nutrition
 Breast tenderness/ soreness
 Wear a supportive and well-fitting bra
 Bra may be worn at night

 Vaginal discharge
 Wear cotton underwear
 Avoid tight fitting pantyhose
 Bathe daily
 Backache
 Emphasize posture
 Avoid standing for long periods
 Apply local heat
 Stoop to lift objects
 Wear good shoes
 Round ligament pain
 Slowly rise from sitting position
 Bend forward to relieve pain
 Avoid twisting motions
 Constipation
 Increase fiber intake in the diet
 Set a regular time for bowel movements
 Drink more fluids
 Avoid caffeinated drinks
 Rest on the left side with the hips and lower extremities elevated
 Hemorrhoids
 Avoid constipation
 Apply witch hazel pads to the hemorrhoids
 Take sitz baths with warm water as often as needed
 Nausea & vomiting
 Dry crackers on arising
 Eat small frequent meals
  Varicosities
 Apply ice packs for reduction of swelling, if preferred over heat
 Walk regularly
 Rest with the feet elevated daily
 Avoid standing for long periods
 Avoid crossing the legs
 Avoid wearing constrictive knee-high stockings; wear support stockings instead
 Ankle edema
 Avoid standing for long periods
 Rest with the feet elevated
 Avoid wearing garments that constrict the lower extremities
 Headache
 Avoid eyestrain
 Rest with a cold cloth on the forehead
 Leg cramps
 Straighten the leg and dorsiflex the ankle
 Avoid pointing the toes
 Increase Calcium intake
 Local heat
 Heartburn
 Small frequent meals
 Decrease fatty and fried foods
 Antacids – avoid those containing phosphorus
 Dizziness
 Slow, deliberate movements
 Support stockings
 Monitor intake

Psychological Adaptation to Pregnancy

 Accepting the pregnancy

 Accepting the baby
 Preparation to parenthood

Health Teachings:
 Weight gain
 Variable, but 25 lb usually appropriate for average woman with single pregnancy
 Woman should have consistent, with only 2-3 lb in first trimester, then average 12 oz
gain every week in second and third trimesters
 Nutrition
 Increase energy & caloric requirements to create new tissue and meet increased
metabolic needs (+300 kcal/ day)
 Protein 60g
 Fat-soluble vitamins (Vit. A, D, E)
  Water-soluble vitamins (Vit.C, Folic acid, Niacin, Riboflavin, Thiamine, Vit. B6, and Vit.
B1)
 Minerals (Calcium (1200mg/day), Phosphorus, Iodine, Iron, and Zinc)

Nutritional Requirement
Calorie : 2, 500 kcal
CHON : 40 grams
Vitamin C : 85 mg
Folic Acid : 600 mg
Calcium : 1,200 mg
Phosphorus : 700 mg
Iron : 30mg

Labor Defined

 The act of giving birth to a child

 A process by which the products of conception are expelled from the uterus
 Series of events by which uterine contractions expel the fetus and the placenta from the
woman’s body

Factors Affecting Labor

PASSENGER

PASSAGEWAY POWERS

PSYCHE PLACENTA
Passenger and Passageway
 Passenger
 Size of the fetal head
 Fetal presentation (cephalic, breech, shoulder)
 Presenting part
 Fetal lie (longitudinal, transverse, oblique)
 Fetal attitude
 Fetal position
 Fetal station
 Passageway
 Type of pelvis (gynecoid)

Power
• SOURCES OF POWER
1. PRIMARY
ORIGINATES FROM THE FUNDUS
• RESPONSIBLE FOR CERVICAL EFFACEMENT AND DILATATION
• FERGUSON REFLEX
2. SECONDARY
• BEARING DOWN EFFORTS OF THE MOTHER
• HAVE NO EFFECT ON CERVICAL EFFACEMENT AND DILATATION

Psyche

 Previous Birth Experience

 Current Pregnancy Experience
 Expectations from current birth experience
 Preparation for birth
 Support system
 Culture

The Placenta

 Site and timing of the placental separation affects labor

 Types of Placental Separation:
 Schultz – from center to margin; presents fetal (smooth) surface
 80%
 Duncan – from margin to center; presents maternal (rough) surface
 20%

Premonitory Signs of Labor

 Lightening
 Occurs when the fetus begins to settle to the pelvic inlet
 The uterus moves downward and the fundus no longer pushes the diaphragm
  Braxton Hick’s Contraction (changes)
 Contractions are becoming painful and characterized as “drawing” sensations of pain
 Bloody Show
 Small amount of blood loss when mucus plug is expelled
 Changes in the Cervix
 Also termed as “ripening”
 Rupture of the Membranes
 Spontaneous labor will proceed within 24 hours
 SROM
 AROM
 Sudden burst of energy
 Occurs approximately 24-48 hours before labor due to unknown cause
 Other signs
 Weight loss
 Increased backache
 Diarrhea; indigestion
 Nausea and vomiting

THE STAGES OF LABOR

Stage 1: Dilatation

 Stage 1 starts from true labor contractions to full dilatation of the cervix
 The stage of dilatation is divided into 3 phases:
CHARS. LATENT ACTIVE TRANSITION

DILATATION 0 – 4cm 4cm – 8cm 8cm – full

CONTRACTIONS Mild Moderate - strong Strong

Every 30 Every 2-5 minutes Every 2-3 minutes
minutes Duration is 45-60 Duration is 60-90 sec
Duration is sec
30-45 sec
PSYCHE Excited with Feels losing Most difficult part on
some degree herself the client
of
apprehension

Stage 1: Nursing Responsibilities

 Hospital Admission
 Assess patient’s hx
  Asses patient’s BOW
 General Examination
 Perform Leopold’s Maneuver
 Determine fetal station (assist in pelvic exam)
 Monitoring and Evaluating
 Assessment of uterine contractions
 Monitor FHT (120-160 bpm)
 Health Teachings and Preparation
 Light meals
 Enema (some institution)
 Perineal Preparation (peri-care, peri-prep)
 Prepare delivery room for birth

Stage 2: Birth or Expulsion

Stage 2 starts right after full cervical dilation to the delivery of the baby

 Mechanisms of Spontaneous Vaginal Delivery

(DF-IR-E-ER-E)
 Descent – fetus goes down in the birth canal
 Flexion – fetal chin bends
 Internal Rotation- at level of ischial spines
 Extension – head extends
 External Rotation – anterior shoulder rotates to AP position
 Expulsion – delivery of the rest of the body

Stage 2: Nursing Responsibilities

 Positioning (lithotomy before)

  High fowlers/ Sitting position
 Coach the patient during pushing and panting
 Assist in the delivery of the baby
 When the head is noted perform Ritgen’s maneuver
 When the head is delivered, palpate the neck for presence of nuchal cord
 Recording

Stage 3: Delivery of Placenta

 Stage 3 starts right after the delivery of the baby to delivery of the placenta

 Types of Placental Delivery

 Schultz – separates from center
to margin; presents the shiny
fetal surface
 Duncan – separates from margin
to center; presents maternal
rough surface
 Signs of Placental Separation
 Uterus becomes round and firm
rising up to level of umbilicus
(Calkin’s sign)
 Sudden gush of blood

Stage 3: Nursing Responsibilities

 Delivery of the placenta, Brandt Andrew maneuver (before)

 Recording
 Inspection of patient’s placenta
 Massage abdomen (uterine fundus)
 Give oxytocin as ordered
 Post partum assessment
 Provide comfort

Stage 4: Recovery
 First two hours after delivery
 Laceration may occur
 Check for lochia
 2ND 3RD 4TH
1ST DEGREE
DEGREE DEGREE DEGREE
VAGINAL VAGINAL VAGINAL VAGINA MUCUS
MUCUS AND MUCUS AND MUCUS AND AND PERINEAL
PERINEAL SKIN PERINEAL SKIN PERINEAL SKIN SKIN

MUSCLES MUSCLES MUSCLES

EXTERNAL ANAL EXTERNAL ANAL

SPHINCTER SPHINCTER

MUCUS
MEMBRANE OF
THE RECTUM

Fourth Stage: Nursing Responsibilities

 Perineal Care
 Inspection of lochia
 RUBRA
DARK RED, 2-3
• SEROSA
PINK TO BROWN, 4-10
• ALBA
COLORLESS TO YELLOWISH, 10 ↑

CARE FOR A POST PARTUM CLIENT

Puerperium/ Post Partum

 Period beginning after delivery and ending when the woman’s body has returned as closely as
possible to its prepregnant state
 Lasts approximately 6 weeks

Assessments
Uterine Changes
 Fundus usually midline and approximately at the level of umbilicus after delivery
 12 hours after delivery, fundus is 1cm above the umbilicus
 After 12 hours, the level of fundus descends approximately 1cm each day until the 10 th day
 10th day fundus descended into the pelvic cavity and can no longer be palpated

 Vaginal discharge (Lochia)

  Usually ceases by 3 weeks and the placental site is completely healed by the 6 th week
○ Rubra (consists of epithelial cells, shreds of membrane, decidua, and blood red)
approximately 2-3 days after delivery
○ Serosa (paler or more brownish in color) approximately 4-6 days after delivery
○ Alba (whitish or yellowish color) approximately 7-10 days after delivery
Cervical Changes
 After 7 days, the external os has narrowed to the size of the pencil opening
 Cervix feels non-gravid again.
 The cervix involves the formation of new muscle cells.

Breast Changes
 Breast engorgement with milk; venous and lymphatic stasis; and swollen, tense, and tender
breast tissue may occur between 3rd and 5th post partum days
 Colostrum (yellowish fluid containing more minerals and protein but less sugar and fat, and
having a laxative effect on the infant) secreted 1 st 2 days post partum
 Mature milk secreted 3 days or less if breastfed immediately after delivery

Emotional and Behavioral Changes

 Rubin’s stage
 “Taking in”
○ exhibits passive, dependent behavior and is concerned with sleep and the intake
of food, both for herself and for the infant
 “Taking hold”
○ initiate action and to function more independently
 “Letting go”

 Post partum depression

 May be experienced about the 3rd post partum day
 Exhibit irritability, poor appetite, insomnia, tearfulness, or crying
 Temporary situation
Blood Volume Changes

 Diuresis between the 2nd and 5th days, as extracellular fluid accumulated during pregnancy is
excreted
 ↓ respiratory rate less than 14 breaths/minute may occur after receiving epidural opioids or
opioid analgesics
 ↑ pulse rate more than 100 beats/minute may be present with increased blood loss, fever, or
pain
 ↓ blood pressure 15 to 20mmHg below baseline pressures may indicate decreased fluid volume
or increased blood loss

Bowel and Bladder Function Changes

 Uterine displacement from the midline suggests bladder distention

 Frequent voidings of small amounts of urine suggest urinary retention with overflow
 Bowel activity may be sluggish because of decreased abdominal muscle tone, anesthetic
effects, effects of progesterone, decreased solid food intake during labor, and prelabor diarrhea
 Pain from hemorrhoids, lacerations, and episiotomies may cause to delay 1 st bowel movement

Other Changes
 Hair loss
 Skin changes
 Small red spots on the face caused by small blood vessels breaking during labor and will
disappear in about a week after delivery
 Stretch marks will eventually fade from reddish purple to silver or white
 Linea nigra may slowly fade as well
 Weight loss
 Lose about 10 lbs during birth (baby, placenta, amniotic fluid)
 Additional weight loss during the first week from left over fluids

Nursing Management

 Assess lochia color and volume

 Check episiotomy and perineum for signs and symptoms of infection
 Assess for attachment/ bonding
 Touching and cuddling
 Naming
 “En face” positioning for direct eye contact
 Reciprocity and rhythmicity in maternal-infant interaction

 Promote successful feeding

 Non-nursing woman (suppress lactation)
 Mechanical methods (tight-fitting brassiere for 72 hours, ice packs, minimize breast
stimulation)
 Nursing woman
 Nipple irritation/ cracking
 Nipple care
 Clean with water, no soap, and dry thoroughly; absorbent pads if leaking
occurs; expose to air
 Position nipple so that infant’s mouth covers a large portion of the areola and
release infant’s mouth from nipple by inserting finger to break suction
 Rotate breastfeeding positions
 Engorgement
 Nurse frequently (every 30 minutes – 3 hours) and long enough to empty breasts
completely
 Warm shower or compresses to stimulate letdown
 Alternate starting breast at each feeding
 Mild analgesic 20 minutes before feeding and ice packs between feedings for
pronounced discomfort
 Plugged ducts
 Area of tenderness and lumpiness often associated with engorgement
 May be relieved by heat and massage prior to feeding
 Expression of breast milk
 To collect milk for supplemental feedings, to relieve breast fullness or to build
milk supply
 May be manually expressed or pumped by a device
 Refrigerated for no more than 48 hours or frozen in plastic bottles in refrigerator
freezer for 2 weeks and deep freezer for 2 months
 Medications
 Most drugs cross into breast milk
 Check with physician before taking any medication
 Postpartum Blues (Day 3-7)
 Normal occurrence of “roller coaster” emotions, weeping, “letdown feeling”
 Usually relieved with emotional support & rest/ sleep
 Report if prolonged or later onset
 Urinary incontinence
 Kegel exercises
 Tighten pubococcygeal muscles, hold for count of 3, then relax; do 10 times TID
 Alternately pour warm & cold water over the vulva
 Let patient listen to running water
 Avoid diuretics such as caffeine
 Catheterization
 Nutrition
 Increased calories, protein, iron, calcium, vitamins
 Increase fluid intake
 Promote ambulation and Exercise
 Kegal and abdominal breathing in PPD 1
 Chin-to-chest on PPD 2 to tighten and firm up abdominal muscles.
  Knee-to-abdomen when perineum has healed to strengthen abdominal and gluteal
muscles

1. Cloasma – mask of pregnancy

2. Naegel’s Rule – computation of Expected Date of Delivery.
3. Bartholew Method- Estimated Age of Gestation by position of the uterus
4. Mc Donald’s Method- Estimated Age of Gestation by measuring the fundic height
5. Striae Gravidarum- stretchmark

Saunders Q & A Review for the NCLEX-RN Examination, 8th edition

Hinkle, Janice L. (2014)Brunner & Suddarth’s text book of Medical Surgical Nursing, 13 th. Philadelphia:
LippincottWilliams & Wilkins.617.0231 H592014

Berman, Audrey. Kozier, Barbara (Eds.) (2008) Kozier & Erb’s fundamentals of nursing: concepts,
process, and practice Upper Saddle River, N.J.:Pearson Prentice Hall, 10th edition
Borromeo, Annabelle R. et.al. (2014). Lewis's Medical-Surgical Nursing: Singapore: Elsevier Mosby.
617.0231 L58 2014, c3
Potter, Patricia A. et.al. ( 2017). Fundamentals of Nursing Vol.1, 9th ed. Singapore Elsevier
Science Direct. (2019). Nursing Process. Retrieved from science Direct:
https://www.sciencedirect.com/topics/nursing-and-health-professions/nursing-process Toney-Butler, T.
J., & Thayer, J. M. (2019). Nursing Process. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK49993

 Compute for the Naegele’s Rule

LMP- August 12, 2019
LMP- March 28, 2020

 Compute for the Age of Gestation

 Fundic height in cm
1. 24 cm
2. 28 cm