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Section I. Anatomy & Physiology 1. Reproductive System a. Female Reproductive System 1) External Genitalia 2) Internal Genitalia 3) Types of Pelvic Ligaments b. 2. 3. Male Reproductive System 1) External & Internal Features
Mammary Glands Reproductive Hormones a. b. Female Reproductive Hormones Other Reproductive Hormones
Menstruation a. b. c. d. e. Menstrual Changes Menstrual Cycle Ovarian Cycle Endometrial / Uterine Cycle Menstrual Disorders
Family Planning a. b. c. d. Natural Conception Barrier Methods Pharmacological Methods Birth Control Summary
Section II. Antepartal Period 1. 2. Assessment of Prenatal Risk Factors Physiological Changes in Pregnancy a. Physiological Changes b. Antepartum Health Promotion Fertilization to Conception a. Fertilization
b. Origin of Body Tissues Fetal Development a. Measuring Age of Gestation
5. 6. 7. 8. 9. 10. 11.
Maternal & Fetal Diagnostic Tests Electronic Fetal Monitoring Laboratory Studies Other Gynecological Procedures Three Common Pregnancy Signs Discomfort Signs of Pregnancy Psychological Changes in Pregnancy a. Maternal Changes in Pregnancy b. Paternal Adaptations in Pregnancy
Section III. Antepartal Complications 1. 2. 3. 4. 5. Abortion Ectopic Pregnancy H-mole Incompetent Cervix Diabetes Mellitus of Pregnancy
6. PIH (Pregnancy Induced Hypertension) 7. Bleeding Disorders in Pregnancy ( Table of Comparison)
a. Placenta Previa b. Abruptio Placenta 8. 9. Vena Cava Syndrome Diseminated Intravascular Coagulation
10. Hyperemesis Gravidarum Section IV. Intrapartum Care 1. Five Factors Affecting Labor (Table of Mechanics of Labor)
a. Passageway 1. Types of Pelvis 2. Pelvic Measurements b. Passenger 1. Fetal Attitude 2. Fetal Lie 3. Fetal presentation 4. Fetal Position c. Power 1. Three Phases of Contraction 2. Characteristics of Contractions d. Placental Factors e. Psyche 2. Labor a. b. c. Signs of Impending Labor Comparison of True & False Labor Stages of Labor 1. Stations of Presenting Part d. e. f. g. 4. 5. Anesthezia Obstetrical Procedures a. b. c. d. e. Preterm Labor PROM (Premature Rupture of the Membranes) Prolapse Cord Dystocia Infection Nursing Considerations during Labor & Delivery Nursing Care during labor Assessing Fetal Heart Rate Cardinal Mechanisms / Movements of Labor
h. Lochia b. Postpartum 1. Complications of Labor & Delivery a. e. Episiotomy 4 . d. e. g. Perineal discomforts b. b. Uterine Involution d. h. f. Preterm Labor PROM ( Premature Rupture of the Membranes) Prolapsed Umbilical Cord Dystocia Infection Precipitate Delivery Uterine rupture Amniotic Fluid embolism Section VI. g. Precipitate Delivery Uterine Rupture Amniotic Fluid Embolism Section V. Postpartum Biophysical changes a. Post Partum Discomforts a. c.f. Breast GI Tract 2. Uterus c.
Breast feedings b. 3. e.Burping & Feeding c. d. f. 4. 3. 7. Spina Bifida Meningocele Myelomeningocele 5 . Post partum Discharge Teachings a.c. 2. g. Assessment Implementation Vital Signs Body Measurement Head to Toe Newborn Assessment Gestational Assessment Newborn Reflexes Basic Teaching Needs of New Parents Preterm Neonates Post term Neonates Other Newborn Abnormalities a. b. Breast Discomforts 3. Neonatal Care 1. Initial Physical Examination & Care of the Newborn a. 6. Psychological Adaptations SECTION VII. b. 5. d. RDS (Respiratory Distress Syndrome) Hemolytic Disease Hyperbilirubinemia Erythroblastosis Fetalis The Newborn of Addicted Mothers SGA (Small Gestational Age) Nervous System Anomalies 1. c. c. 8. 2.
Unit 3 MATERNAL AND CHILD HEALTH NURSING Section I ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM 6 .
capable of stretching during the birth process. LABIA MAJORA -W/ hair outside but smooth inside fatty skin folds from MONS PUBIS to PERINEUM and protects the labia minora . smooth. helps improve sperm survival Doderleins Bacillus: causes the vaginal ph to be acidic. w/in it is the major blood supply of clitoris 7 . Covers and protects VESTIBULE VAGINAL INTROITUS CLITORIS URETHRAL MEATUS TWO GLANDS THAT LUBRICATE DURING SEX 1. touch and temperature. opens approximately 1cm below clitoris -Composed of glans & shaft that is partially covered by prepuce -GLANS is small and round and is filled w/ many nerve endings and rich blood supply -SHAFT is a cord connecting the glans to the pubic bone. It is formed by the frenulum and the prepuce of the clitoris which is also very sensitive because it has rich nerve supply. which forms lactic acid Hymen: the elastic tissue. The glands of labia minora lubricate the vulva. to accommodate the delivery of the fetus. lies directly over symphysis pubis & becomes covered w/ hair just before puberty It is where the pubic hair grows. SKENES GLANDS (Paraurethral Glands): lubricates the external genitalia 2. -Entrance of urethra. Thorn & bloody during forced sexual act RUGAE: thick folds of membranous stratified epitheliums on the internal wall of the vagina. urinary meatus & vagina LABIA MINORA -Thin. extremely sensitive to pressure.a External Genitalia (Vulva/Pudendum) MONS PUBIS -Soft fatty tissue. Bartholins Gland (Vulvovaginal Glands): alkaline in ph. pink. hairless.I. symbolizes virginity.
permanent closure of the internal cervical os. Nourishment for fetal growth. the portion also where palpation is done. until the 38th week after which is separated – TREATMENT FOR INCOMPETENT CERVIX and PREVIOUS ABORTION. This is where the cerclage is done for incompetent cervix. provide a place for implantation of the ova 3. NOTES Layers of the Uterus: 1. Namely: A. Cervix : lowest portion . The part that contracts during hemorrhage. II. 1/3 of the total uterus External Os: where the nurse obtain the Pap Smear to the SQUAMOCOLUMNAR JUNCTION cells. Myometrium: LARGEST PORTION EXPELS THE FETUS DURING THE BIRTH PROCESS. III. Shirodkar Barter Suture. SHED DURING MENSTRUATION. Isthmus: shortest portion of the uterus. STRUCTURE Divisions of the uterus I. the portion that is cut when the fetus is delivered during cesarean birth. Endometrium: inner layer. Internal Genitalia (Figure 1-a) ORGAN Uterus FUNCTIONS Pear shape muscular organ which has three(3) main functions 1. Mc Donalds or Purse String Cerclage of the external os: usually Normal spontaneous delivery will be done for the patient.TH E NON-PREGNANT UTERUS 2. most vascular. B. 1. Perimetrium: Outer most layer. Prevents hemorrhage. Also touching it by the tip of the fingers during contraction is the best method to determine the intensity of contractions during labor. 8 . Fundus: Upper segment. receive the ova from the fallopian tube 2.Figure 1-a Internal Structure Ib. this is the most vascular. Aids for support & added strength.
Responsible for the production.Bandl’s Ring ( Pathological Retraction Ring): seen in Prolonged Labor or Dystocia Fallopian tubes Site of fertilization of the ovum with perm Ovaries Ovulation (the release of an ovum). Pair of follicle containing organs on the other side of the uterus Ovaries: 4 by 2 cm in diameter. 1. uterus & ovaries 9 . Isthmus: the portion that is cut or sealed in TUBAL LIGATION ( site for sterilization) 3. frequent site for ectopic pregnancy. and discharge of ova Secretion of estrogen and progesterone Cortex of the Ovaries. 3. Round: remain lax during non-pregnancy & become HYPERTROPHIED & elongated during 2. this is also the LONGEST portion. Steroid hormone production 4 Parts of the Fallopian tubes 1. Types of Pelvic Ligaments 1. Vagina Organ for coitus. pregnancy. The ovaries lie in the upper pelvic cavity. Tube extending from the introitus to cervix Fallopian tubes transport the ova from the ovaries to the uterus. Birth canal. Maturation.5 cm thick. developing and graafian follicles are found here. Conduit for menstrual flow. Infundibular: covered by the Fimbriae cells that help guide the ova to the Fallopian Tube. Interstitial : lies within the uterine wall 2. 4. Cardinal: chief uterine supports Broad ligaments: drapes over the fallopian tubes. Ampulla: where fertilization occurs . Fibromuscular lined with membrane organ mucus I c.
Cowpers Gland/ Bulbo-urethral: secretes also semen SEMEN sources: 1. Seminal vesicles : 30% 3. Cowpers : 5% 10 . Epididymis : 5% 4. corpus spongiosum Internal Features: MALE REPRODUCTIVE SYSTEM Epididymis: totals 20 ft. Corpus cavernosa b. B External Features: 2 Erectile Tissues in the penis: a. prostrate gland : 60% 2. WHERE SPERMS ARE STORED Vas / Ductus Deferens: carries the sperm to the inguinal canal Seminal Gland / Vesicle: Secretes SEMEN Prostrate Gland: secretes SEMEN also.I.
Accessory Structures Figure 1-b Mammary Glands III. milk flows to the alveoli and then thru the duct system further going to the balloon like storage sacs called LACTIFEROUS SINUSES NIPPLES -Sinuses merge into openings on nipple 11 . Mammary Glands MAMMARY GLANDS -2 mammary glands located on each side of chest wall -Each breast 15-20 lobes containing clusters of ALVEOLI ACINI -Saclike end of the glandular system -Lined both w/ epithelial cells that secrete colostrum( whic h is rich in IgA) & milk & w/ muscles that expel milk DUCTULES -Exit alveoli & join to form larger canals LACTIFEROUS DUCTS -During lactation.
12 . Other functions Progesterone *Produce from corpus luteum. Stimul ates uterine contractions & smuscular peristalsis of the fallopian tubes for the passage of the ovum to the uterus. Decrease uterine motility/ contractility during pregnancy C. Thickens the endometrium d. placenta -Secretes thick/viscous cervical secretions. Stimulates the dev’t of acini cells in the breast(major cells for breast milk) Increase the endometriums supply of glycogen. Female Reproductive Hormones HORMONES Follicle Stimulating Hormone *Stimulates Graafian follicle to mature and resulting in increase levels of estrogen smooth muscles Inhibits the secretion of FSH b. Stimul LUTENIZING HORMONE AND ESTROGEN peak immediately before ovulation Lutenizing Hormone -When follicle is ripe and mature. Respo nsible for the increase vaginal secretion in the vagina (LEUKORRHEA) c. Responsi ble for the dev’t of 2ndary sex characteristics in females f. A. and placenta -Assists in maturation of Graafian follicle -Stimulates thickening of endometrium. triggers follicular rupture and release of ovum -Peaks at 16-18 hours before ovulation. Enhances placental growth E. Mildly increases Na & water reabsorption h.IV. g.Preparation of the uterus to receive a fertilized ovum B. oxygen & amino acids for maintaining pregnancy a. adrenal cortex. -stimulates ovulation & development of corpus luteum Estrogen -Produce from ovaries. Contracts Most women ovulate two weeks before the beginning of the next period. Increases basal metabolism D. SUPPRE SSES THE FSH & Prolactin e.
Other Reproductive Hormones 1. Pre-Menstrual Phase (22 days to 28 days) -If fertilization does not occur. Sexual intercourse during menstruation is not harmful. Human Chorionic Gonadotropin -Increases in nausea and vomiting Responsible for Hyperemesis Gravidarum V. -Endometrium degenerated/ sheds. MENSTRUATION Menarche: 1st menstrual period.menstruation occurs.triggers/stimulate the production of FSH. Menstrual Cycle: 1. Secretory Phase (15 to 21 days) Progesterone Phase (Corpus Luteum: Progesterone) Other Books it is called: Luteal Phase After Ovulation-----release of mature ovum from the Graafian follicle-----Graafian Follicles die and replaced by Corpus Luteum-----secretes progesterone Functions of Progesterone: 4. Menstrual Phase ( 1 – 14 days) -Corpus luteum dies.Estrogen Phase ( 6 – 14 days) Graafian Follicle: Estrogen Anterior Pituitary Gland secretes FSH stimulates the development of the Graafian follicle (secretes Estrogen) suppresses FSH & stimulates LH LH stimulates ovulation Increase Estrogen kills/decreases FSH 3. -Progesterone & Estrogen vanishes. Proliferative Phase.o. Melanocyte Stimulating Hormone -Responsible for the linea nigra & chloasma in pregnancy -Secreted by the anterior pituitary hormone MELANOTROPIN -Will end on the 2nd month of pregnancy 3. Menopause: cessation of menstrual cycle that occurs normally from 40 & 55 y. Lactogenic Hormone (Prolactin) -Stimulates lactation 2.IV a. 2. corpus luteum begins to die -Progesterone & Estrogen decreases -Endometrium degenerates -Menstruation stops during pregnancy because there is decrease secretion of hormones by the ovary. usually age 12. 13 . but may begin as early as 9.
progesterone level is maintained at high level -Progesterone level decreases -Corpus albicans Sloughing off of endometrial lining PREMENSTRUAL PHASE -endometrium degenerates 14 . corpus luteum degenerates 10 days after ovulation -WITH FERTILIZATION. concepts produces HCG that sustains life corpus luteum.OVARIAN CYCLE (ACORDING TO HORMONAL ACTIVITY) 0 7 14 OVULATION 21 CORPUS LUTEUM 28 LUTEAL REGRESSION DEVELOPING FOLLICLES FOLLICULAR PHASE Ovarian follicles mature under influence of FSH and estrogen LH surge causes ovulation -mittelshmerz -cervical changes -increase BBT LUTEAL PHASE ENDOMETRIAL/UTERINE CYCLE (Described by varying thickness of the endometrium) (Figure 1-c) MENSTRUAL PHASE -Menstruation -Decrease estrogen -Decrease progesterone PROLEFERATIVE PHASE -Hypothalamus secretes FSH -APG (anterior pituitary gland) secretes FSH -Maturation of Graafian follicle -Increased estrogen -Hypothalamus stops FSH & starts LH -APG stops FSH & starts LH secretion SECRETORY PHASE -Formation of corpus luteum -Increase progesterone -NO FERTILIZATION.
Depression . structural/congeni tal abnormality Secondary– Cessation of menstruation Menorrhagia -Excessive prolonged bleeding or Metrorrhagia .Abdominal bloating .Irregular bleeding in between periods VI. the nurse must: EVALUATE HER OWN BELIEFS & VALUES REGARDING FAMILY PLANNING!!!! 15 .Figure 1-c Menstrual Cycle V.Crying .Weight gain . diet & lack of prenatal care) Before counseling a patient about contraceptive methods. a Menstrual Disorders Dysmenorrheal .Headache -Breast tenderness .SecondaryMay be caused by tumor/inflammat ory conditions Premenstrual Syndrome -Edema of lower extremities .Loss of concentration Amenorrhea PrimaryNever menstruated. FAMILY PLANNING AND CONTRACEPTION Family Planning Methods The most important topic in a Prenatal Visit is the DANGER SIGNS IN PREGNANCY!! Discharge planning should start 0n the admission to the facility: to introduce to the community & support services!!! #1 Initial Responsibility of a Nurse in Pregnant Adolescents is to impress the importance of Prenatal care: cause they are often PRONE to PIH dev’t factors such as -( age.PrimaryNo known cause .
since this is difficult to accurately determine. BBT. some women experience pain when the ovary releases egg * Rarely accompanied by scant vaginal spotting * Some couple uses this as signal of the beginning period and to avoid sexual intercourse until the fertile period passes 16 . Sympto thermal: mixture of Cervical Mucus & Basal Body Temperature 5. Daily Basal Body Temperature: will drop from 0. Coitus Interruptus : oldest & least effective method. The determination of infertility is based on age. the time period is reduced to 6 months of unprotected intercourse. THIN & ELASTIC. In a couple younger than 30 years old. Natural methods of birth control generally have a higher failure rate because it depends on knowing when the ovulation occurs. transparent. infertility is defined as failure to conceive after 1 year of unprotected intercourse. CLEAR. Natural Contraceptives 1. In a couple age 30 or older.8 F In Basal body temperature method the patient should take her temperature every morning upon awakening and prior to any activity to avoid the temperature being influenced CERVICAL MUCUS METHOD * Uses the appearance. 2. characteristics and amount of cervical mucus to identify ovulation Ovulatory: cervical mucus is clear and abundant Pre-ovulatory / post ovulatory: cervical mucus is yellowish. 3. the chance of miscalculation is high. immediately after awakening.2 – 0. Greatest Factor for Basal Body Temperature DISTURBANCE---will be the presence of stress. SYMPOTHE RMAL METHOD * Couple makes use of combination of calendar. and cervical mucus method to determine fertile period MITTELSCHMERZ COITUS INTERRUPTS * Requires withdrawal of the penis from the vagina before ejaculation * Between menstrual cycles. Calendar Method: to determine her FERTILITY. Don’t have sex on the 1st day of menses unt6il 3rd day of temperature elevation.8 degrees Fahrenheit during ovulation in response to PROGESTERONE. Monitor for at least 3 months before analyzing the results!!!! Most accurate reading. before arising!!!! 4. less abundant. and sticky (inhibit sperm motility) . Billings Method (Cervical Mucus): with ovulation (peak day) the mucus becomes thin and watery.avoid having sex in this phase).2 F-0.Natural or Fertility Awareness Methods A. SPINNBARKEIT. subtract 18 days from the SHORTEST MENSTRUAL CYCLE & 11 days from her longest cycle. CALENDA R METHOD Relies on abstinence from intercourse during fertile period BASAL BODY TEMPERATURE * Measured by taking & recording e temperature rally rectally each morning before waking after at least 3 hours of sleep * Drops before ovulation and rises 0.
squeeze and 17 . Until both partners are familiar with the Reality condom. thus defeating the condom's purpose. Otherwise there is the chance that the penis will be inserted outside the condom into the vagina. bleeding. Removing the female condom The female condom should be removed following intercourse and before standing up.Foul vaginal discharge -Spotting. or heavy menstrual periods .Long polyurethane sheath that is inserted manually into vagina with a flexible internal ring extending to cover the perineum . To remove. Use of the male condom with the female condom is not recommended.Rubber sheath that fits over the erect penis and prevents sperm from entering the vagina IUD -Flexible device inserted into the uterine cavity -It alters uterine transport of the sperm so fertilization don’t occur DANGER SIGNS TO REPORT: . because rubbing the latex male condom against the polyurethane female condom creates friction that may make intercourse difficult.Lubricated with a spermicide (non-oxynol-9) .It can be inserted up to 8 hrs before intercourse MALE CONDOM . B. the penis should be guided by hand into the open ring.by other factors.Spontaneous expulsion occur in 2%-10% of users in the first year Figure 1-d Condom NCLEX TIPS!! The female condom during sex Figure 1-d During sex the penis is inserted into the center of the open ring at the opening of the vagina. Barrier Methods FEMALE CONDOM (VAGINAL POUCH) .Late or missed menstrual period -Severe abdominal pain -Fever and chills .
it also comes with a tube of lubricant in the package. but there still is a slight risk. CERVICAL CAP VS DIAPHRAGM CHARACTERISTICS DESCRIPTION EFFECTIVITY USAGE SPERMICIDE SIDE EFFECTS Fitted by health provider HOW TO INSERT Not longer than 48 hours DURATION CERVICAL CAP Small rubber plastic that fits snugly over cervix NULLIPARA=80% MLTIPARA=60% Continuous protection 24 hours regardless of the number of times of sexual intercourse Not necessary for repeated coitus Cervicitis DIAPHRAGM (Figure 1-e) Flexible ring covered with dome shape rubber cap 80% with typical use On two hours prior to sexual intercourse and in place for 6 hours after Use every coitus Cystitis.Use a new condom each time you have sexual intercourse. rectal prolapsed Toxic Shock syndrome (TSS) Same.Although the Reality condom is prelubricated. acute cervicitis 18 . Gently pull the condom from the vagina.The female condom works only if you use it every time you have sex. ALWAYS CHECK FOR TEARS & HOLES!!! Contraindicated for: Frequent UTI. .twist the outer ring to ensure that semen remains inside the condom. . refitted after birth and weight loss of 15lbs Not longer than 24 hours A diaphragm should be left in the vagina 6-8 hours after sexual intercourse. Do not reuse the female condom. or other jewelry when inserting and removing the condom. You may wish to add a few drops of lubricant to the opening of the condom or to the penis. Diaphragm: should remain in place 6-8 hours after sex & maybe left for 24 hours.You can still become pregnant and transmit or acquire a sexually transmitted disease while using the female condom. Discard in the trash. cystocele & rectocele. . Lubricants reduce friction and noise those results from friction. . as it may clog the toilet or sewer lines. cramps. . ring.Use caution to avoid tearing the female condom with a sharp fingernail. Prolapsed Cord & Retroverted Uterus.Remove tampons before inserting the female condom. The risk is less than if you do not use the condom. Do not attempt to flush the condom down the toilet. Important points to remember when using the female condom . Do not reuse.
If the patient forgets to take 2 tablets for the next 2 days. C. hyperviscosity Contraindicated for DIABETICS.Headaches.DIC. smoking & diabetics.A. . H. she should take 2 tablets NEXT 2 DAYS!!! And use another contraceptive method for the rest of the cycle.eye problems & S-severe leg cramps . she should discard the remaining tablets & use another contraceptive method for the rest of the cycle.Chest pain.ATTN: Severe Headaches maybe an indication of Hypertension!!!! CONTRAINDICATED: 1 Thromboembolism 2 CVA. inhibiting implantation into endometrium Norplant Inserted subdermally SUBCUTANEOUS INJECTIONS Medroxyprogesterone (DMPA or DEPOVERA) 19 .Stops LH & FSH STOP IF WITH THE FF: (ACHES) . Pharmacologic methods Oral Contraceptive Pill: synthetic estrogen combined with small amounts of synthetic progesterone-preventing ovulation by stopping FSH & LH.abdominal pain. ORAL CONTRCEPTIVES Use to prevent conception by inhibiting ovulation (inhibits release of FSH and LH) Causes atrophic changes in the endometrium to prevent implantation of egg Causes thickening of cervical mucus to inhibit sperm travel MINIPILLS Pills contain progestin but no estrogen Pills must be taken each day and preferably same time each day to achieve maximal effectiveness Thins and atrophy endometrium and thickens cervical SUBDERMAL IMPLANTS Six soft sillastic rods filled with synthetic progesterone implanted into the woman’s arm Progesterone leaks into the blood stream. The best for diabetics are Barrier Contraceptives--Condom & Diaphragm Examples: Demulen (Ethinyl Estradiol Ethylnodiol ) a monophasic oral contraceptive agent. If she misses 3 or more.Figure 1-e Diaphragm C. E. HPN.
or suppositories that are inserted into the vagina to kill over the against sexually sperm before they can enter the uterus. 6 implantable capsules are inserted at one time Birth Control Summary Table RISKS OR POSSIBLE PROBLEMS BIRTH CONTROL METHOD ADVANTAGE Spermicides: chemicals in the form of foams.Avoid using petroleum over the jelly of oil base counter products. creams. protect against STD 20 . typical use effectiveness: 84% (male) 79% (female) transmissio • May break during n intercourse • Available . • Available • Only partially effective films. both may be used with a STD • Lessens sensation spermicide. female condom is a plastic sac with a ring against latex or spermicide on each end inserted into the vagina. mucous ADVANTAGE: can be use immediately postpartum if client is not breastfeeding and 6 weeks if breastfeeding Women taking the minipill have a higher incidence of tubal and ectopic pregnancies. Under ideal conditions the sperm can reach the ovum 1 to 5 minutes after ejaculation. female hypogonadism. typical use effectiveness: counter transmitted disease 70% • Can be used (STD) transmission with other • Possible allergies or methods to irritation improve effectivenes s Condom: male condom is a sheath of latex or animal tissue • Effective • Possible allergies to placed on erect penis. and premenstrual syndrome aren't associated with progestin-only oral contraceptives. jellies. possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis. Combined estrogen and progesterone preparation in tablet form and are taken daily with combinations of hormones Oral contraceptives prevent pregnancy by suppressing FSH (follicle stimulating hormone) and LH (leutenizing hormone) release from the pituitary gland thereby blocking ovulation. it can cause • Can be used INCREASE FRICTION with other which will lead to methods to TEARING OF THE further LATEX CONDOM. into the midportion of the upper arm about 8-10cm above the elbow crease.
used with spermicide. typical use effectiveness: 99% for up to rarely. May use spermicide size before use. egg. It does not with an unusual cervix leak. typical use effectiveness: 82% • Reusable • Not effective against • Can last for STD transmission one to two • Needs to be fitted by a years health care professional • Increased risk of bladder infection • Possible allergies to latex or spermicide Cervical Cap: thimble-shaped latex cap inserted into vagina over • Reusable • Not effective against cervix to prevent sperm from entering uterus. permits sexual spontaneity • Can be 21 . prior to headaches. one pill taken daily prevents ovaries from releasing eggs and/or thickens cervical mucus to prevent sperm from reaching egg. ovarian cysts Hormonal Implant (Norplant): six small capsules inserted by a • Protects • Not effective against health care professional under the skin of upper arm that deliver against STD transmission small amounts of hormone to prevent ovaries from releasing pregnancy • Possible scarring or. nausea. • Difficult for some women to insert Birth Control Pill: prescription drug containing female hormones. typical use effectiveness: 82% one to two • Needs to be fitted by a years health care professional • Difficult to fit women CERVICAL CAP: can be retained upto 48 hours. noncancer ous breast tumors. infection at five years insertion site • No action • Side effects include required irregular bleeding. sexual depression intercourse. intercourse. Cannot be re-applied again after use. particularly in women permits over 35 years who sexual smoke spontaneity • Must be taken daily • Some protection against ovarian and endometria l cancer. typical use effectiveness: 94% • More • Not effective against regular STD transmission periods • Rare but dangerous • No action complications. used with • Can last for STD transmission spermicide.Diaphragm: shallow latex cup with flexible rim inserted into vagina over cervix to prevent sperm from entering uterus. required including blood prior to clotting and sexual hypertension.
AIDS • Not effective against STD transmission • Side effects include irregular bleeding. permits sexual spontaneity • Can be used while breastfeeding beginning six weeks after delivering baby • Protects against cancer of the uterine lining and iron deficiency anemia Intrauterine Device (IUD): small device inserted by a health care • Effective professional into the uterus. depending Intra-uterine Devices (IUD). heavier periods • Increased risk of pelvic inflammatory disorder(PID) within first four months after insertion • Rare risk of uterine perforation 22 . History of PID: a woman using IUD has 50% chance of getting PID. prevents eggs from being fertilized one to six and/or implanting in uterus. typical use effectiveness: 96% years. Spontaneous sexual Expulsion of the device: Myometrium irritability c. Cramping & fever permits Contraindications: sexual spontaneity 1. Excessive Menstrual flow (menorrhagia) b. Ectopic Pregnancy. headaches.a small plastic object is on type inserted into the uterus where it remains in place. required Most Frequent Side Effect: prior to a. abdominal pain • Side effects do not reverse until medication wears off • May cause delay in becoming pregnant after injections are stopped • Not effective against STD transmission • May cause spotting between periods and longer. It interferes used with the ability of the ovum to develop as it transverses the • No action fallopian tube. depression. intercourse. 2.used while breastfeeding beginning six weeks after delivering baby Hormonal Injection (Depo-Provera): injection given by a health • Protects care professional in the arm or buttock every 12 weeks to against prevent ovaries from releasing an egg and/or thicken cervical pregnancy mucus to keep sperm from reaching an egg. weight gain. typical use for 12 effectiveness: 99% weeks • No action required prior to sexual intercourse.
swelling. because it 23 . typical use protection STD transmission effectiveness: 99% from • Reactions to surgery pregnancy may include infection. permits sexual spontaneity • Not effective against STD transmission • Reactions to surgery may include infection. injury to intestine. or deferens. prior to sexual intercourse. sexual spontaneity Generally it requires 6 – 36 ejaculations to render neg. typical use effectiveness: 99% • Permanent protection from pregnancy • No action Tubal ligation: isthmus part in the fallopian tube is the usual required part being lighted. Surgical sterilization of the male involves cutting the ductus • No action required bruising. sex after one week or when the sperm count indicates 0 permits count or 2 negative sperm count have been examined. collect them in a clean glass not plastic. bleeding. Never use / give IUD to NULLIPAROUS WOMEN!!! Return to the clinic for evaluation after her 1st menses!!! Figure Intra uterine device (IUD) Tubal Ligation: surgical procedure to permanently block woman's Fallopian tubes to prevent eggs from reaching sperm. prior to tenderness of scrotum sexual • Irreversible Vasectomy: Vas Deferens is cut. reaction to anesthesia • Increased chance of ectopic pregnancy • Irreversible Vasectomy: surgical procedure to permanently block the male's • Permanent • Not effective against vas deferens to prevent sperm from reaching eggs. The man can resume intercourse. blood clot near testes. sperm count In order to get for semen analysis.
Pregnancy Induced Hypertension 3. to determine the days when body is most fertile.1st time Pregnancy Primipara . Natural Family Planning: techniques. Chromosomal Disorders in infants 2. Toxoplasmosis (protozoa) 24 . Cesarean Delivery Primigravida . The first portion of the semen has a high ration of sperm. Nulligravida . PIH 3. Cephalopelvic Disproportion Women over 35 years old are at Risk for: 1. Assessment of Risk Factors in the Prenatal Period Age of Pregnant Women -17 below: Have a higher incidence of 1. No sex for 3 days before the semen collection & no drinking of alcohol for 1 day.may affect the spermatozoa.never been pregnant Infections: Use TORCH T O R C H Toxoplasmosis Other infections Rubella Cytomegalovirus Herpes A. Prematurity 2. including checking body temperature or cervical mucus daily or recording menstrual cycles on a calendar. typical use effectiveness: 81% • No medical • Not effective against or hormonal STD transmission side effects • Requires strict • Inexpensive recordkeeping • Accepted • Illness or lack of sleep by most may affect body religions temperature • Vaginal infections and douches may affect cervical mucus • Requires abstinence from sexual intercourse or alternative contraception during fertile days Section II Antepartum Period I.1st delivery of a live infant.
or inner thigh area (strict precautions are necessary to protect the fetus during delivery) No vaginal examinations are done in the presence of active vaginal herpetic lesions Maintain CONTACT isolation procedures during hospitalization if the disease is active Neonate and mother may be separated during the active period.Anesthetic O . intrauterine growth retardation and the potential for a sick. and brain Women with low rubella titers should be vaccinated at least 3 months before becoming pregnant or following a delivery NOTE: Any woman in the first trimester of pregnancy is at risk if exposed to rubella. Rubella Extremely teratogenic in first trimester Causes congenital defects of eyes. Physiological Changes in Pregnancy 25 . heart defects. flu-like infection in mother Transmitted through raw meat or handling cat litter of infected cats Spontaneous abortion likely to occur early in pregnancy B.Anti-malarial S . Herpes Simples Affects the external genitalia. addicted infant II. perineal. delivery may be performed vaginally if the lesions are in the anal.Produces symptoms of acute. deafness No effective treatment available D.Salicylates A . fetal alcohol syndrome Nicotine: increases vasoconstriction. Coccaine: The effect of cocaine in a labor and the fetus is preterm labor thus increased uterine contractions. and cervix Causes draining. Congenital Fetal defects often results from such an infection.Produces flu-like or mononucleosis-like symptoms in the mother Transmitted through the respiratory or sexual route May cause fetal death. vagina. SGA (small gestational age). heart. retardation. ears. Cytomegalovirus (CMV) . C. Mongolism. painful vesicles Delivery of the fetus is usually by cesarean section active lesions are present in the vagina. low birth weight Heroin addict: babies are born with an EXAGGERATED/ HYPERACTIVE CNS / REFLEXES or CNS IRRITABILITY.Oral hypoglycemics Substance Abuse: Alcohol: causes learning disabilities. or other special precautionary measures may be used to avoid transmission to neonate Teratogenic Drugs: BASA-O(code) B .Barbiturates A . retardation.
from 32-36 weeks (more frequently if problems exist) c. PARA – number of pregnancies that lasted more than 20 weeks. • Increase normal dependent Edema (bilateral or ankle edema) normal for 36 weeks gestation. Produce by the corpus luteum. Lordosis: the Pride of Pregnancy Relaxin: responsible hormone for the softening of the pelvic cartilages. Normal delivery blood loss: 300 – 400 ml of blood Cesarean Section: 800 – 1000 ml II a. Antepartum Health Promotion Prenatal Visit Schedule of visit if with no complications: a.ANEMIA) • Decrease gastrointestinal motility & peristalsis due to displacement of the intestine & compression of the stomach. • Decrease Urine Specific gravity: a result of increase Urinary Output. ---leading to CONSTIPATION. PRETERM – newborn born before 37 weeks of gestation. PRIMIGRAVIDA – pregnant for the first time. usually around 18 to 20 weeks. contributes to the waddling gait typically noted in pregnancy. including present pregnancy. quickening occurs around 20 to 22 weeks.30% during 1st – 2nd trimester to meet increase tissue demand • Increase secretion of sugar (Glycosuria) • INCREASE PLAMA VOLUME • Increase Urinary Frequency due to pressure to bladder. Every 4 weeks. Decreases during pregnancy • Decrease (slightly of blood pressure) in the 2nd trimester due to decrease peripheral resistance • Decrease Hemoglobin & Hematocrit because of Iron Deficiency (Pseudo.Increases during pregnancy • Increase Heart Rate for 10-15 beats/minute • Increase Cardiac Output for 20% . NULLIPARA – a woman who has not given birth to a baby beyond 20 weeks gestation. Others: Chloasma : Mask of pregnancy Leukorrhea: whitish vaginal discharge without signs of inflammation & itching. up to 32 weeks b. It's important for the nurse to distinguish between a client who's having her first baby and one who has already had a baby. Women who have had children will feel quickening earlier. Operculum: formation of mucus plug in CERVIX to seal out bacteria. Every 2 weeks. For the client who's pregnant for the first time. PRIMIPARA – a woman who has given birth to one baby more than 20 weeks gestation. Every week from 36-40 weeks Classifications of Pregnancy GRAVIDA – number of times pregnant. MULTIPARA – a woman who has had two or more births at more than 20 weeks gestation. because they recognize the sensations. MULTIGRAVIDA – pregnant for second or subsequent time. 26 . Note: Twins or triplets counted as 1 para. regardless of duration.
Iron Deficiency Anemia is a result of PICA. strengthening the abdominal muscles. A diet of 2500 calories per day An increase of about 500 calories per day is needed during LACTATION. done by tightening the buttocks & flattens the lower back against the floor for one minute. Abdominal breathing ( during latent phase of Stage 1 Labor) 1.TERM – newborn born after 37 weeks to 40 weeks of gestation. Abdominal muscle Contractions: prevent constipation in pregnancy. Number of premature births. Fertilization to Conception Fertilization: the union of the ovum & sperm. Increase elasticity of the Pubococcygeus muscle. with approximately six to nine breaths per minute B. determination. All exhalations are a blowing motion III. A more rapid pattern. The start of Mitotic cell division & fetal sex 27 . Used until labor is more advanced 2. Pelvic Rocking: Relieves backache during pregnancy. Done 50-100 times. Pant-pant-blow( during Transitional Phase of Stage 1 Labor) 1. DIFFERENT TYPES OF BREATHING TECHNIQUES - Number of terms births. press stress incontinence. done in standing or lying position. The abdomen moves outward during inhalation and downward during exhalation 3. rectum. Parity (TPAL) T P A L NUTRITION 1st Trimester: 2 –4 lbs gain / 30-35 calories/kg/day 2nd trimester: 1 lb per week / 200 calories/kg/day 3rd trimester: 1 lb per week/ 200 calories/kg/day Pregnant Women needs 300 extra calories PER DAY for adequate nutrition. increase sexual responsiveness. Used in advanced labor 2. Efficient for Urinary Frequency & Hemorrhoids. Examples: Tightening & strengthening the muscles of the Vagina. consisting of two short blows from the mouth followed by a longer blow 3. Different types of Exercises Pelvic Floor Contractions (Kegel’s Exercise): Promotes perineal healing. Number of living children A. perineum & then relax after. POST-TERM – newborn born after 40 weeks of gestation. The rate remains slow. Number of Abortions.
X & Y. decrease the acidity of the vagina so as to INCREASE THE MOTILITY OF THE SPERM. Fetus: From 5-8 weeks until term The ovum is said to be viable for 24-36 hours. a mulberry & Bumpy appearance will follow morula (figure 1-F) ---after 3-4 days. responsible for the dev’t of placenta & fetal membrane.the frequent medication to alter the vaginal ph. > Functional Life of spermatozoa is 48 hours > XX= female.> Primary oocyte (immature ovum) contains Diploid number of chromosomes (46). Zygote migrate for 4 days in the body of the uterus (Mitosis will take place-Cleavage formation will begin) After 16-50 cell formation from mitosis. > Gamete (mature ovum): is a cell or ovum that has undergone Maturation & will be ready for fertilization. Sodium Bicarbonate. Cells in the outer ring are called Trophoblast (later it forms the placenta. the structure will be ball like in appearance which will be called Blastocyst. Terms to remember: Ovum: From ovulation to fertilization Zygote: From fertilization to implantation Embryo: From implantation to 5-8 weeks. Cells in the inner ring are called Erythroblast cells (which will be the embryo). > One oocyte contains a haploid (23) number of chromosomes after division. Sperms move by flagella & Penetrate the & dissolve the cell wall of the ovum by releasing a proteolytic enzyme (Hyaluronidase) After penetration Fusion will result to Zygote. XY= male. > A sperm carries 2 types of sex chromosomes. Figure 1-F Morula Process of Fertilization: After ovulation ovum will be expelled from the Graafian follicles ovum will be surrounded by Zona Pellucida (mucopolysaccharide fluid) & a circle of cells (Corona Radiata) which increases the bulk of the Ovum expelled from the Fallopian Tube by the Fimbriae (infundibulum). > One gamete carries 23 chromosomes. 28 . > 400 million sperm cells in one ejaculation.
Figure 1-G Fetal Membranes Fetal Membranes: membranes that surround the fetus, & give the placenta the shiny appearance. (Figure 1-G) 2 Layers: a. Amnion: shiny membrane on the 2nd week of Embryonic Development & encloses the Amniotic Cavity b. Chorion: Outer membrane that supports the sac of the amniotic fluid. Chorionic Villi: finger like projections from the chorion. This is the place where gases, nutrients and waste products between the maternal & fetal blood takes place. Amniotic Fluid: surrounds the embryo, contains fetal urine, lanugo from fetal skin & epithelial cells. Ph is 7. 2. Specific Gravity: 1.005 – 1.025 Normal Amount: 500 – 1000 ml. Oligohydramniosless than 300 ml. Polyhydramniosmore than 2000 ml. observe for Down syndrome & congenital defects Functions of Amniotic Fluid: a. Protects the fetus from changes in the temperature & cushion against injury. b. Protects the umbilical cord from pressure, the fetus drinks & breaths the fluid into the lungs. Amniotic Fluid Colors: Normal color: transparent, clear, with white tiny specks Dark amber or yellow: Ominous sign of presence of Bilirubin, hemolytic disease Port Wine Colored: Abruptio Placenta Greenish: Meconium Stained / FETAL DISTRESS: always go for Cesarian Section! Also if ph is less than 7.2 If with odor: deliver within 24 hours, may indicate infection. Umbilical Cord: 21 inches in length & 2 cm in thick ness, circulatory communication of the fetus to the mother. CONTAINS 2 ARTERIES & 1 VEIN. Covered by a gelatinous mucopolysaccharide called Whartons jelly. Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium. During the 2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the 3rd week of development (21 days after implantation), the
embryonic disk evolves into three layers, and three new structures — the primitive streak, notochord, and allantois — form. Early during the 4th week (28 days after implantation), cellular differentiation and organization occur.
Figure 1-H Fertilization Cycle Table Summary from Fertilization to Implantation (Figure 1-H)
PRE-FERTILIZATION ACTIVITIES Ovum moves to amulla of fallopian tubes Capacitation Acrosome reaction
CONCEPTION Zona reaction
IMPLANTATION Morula (after 34 days implantation) Blastocyst (trophoblast; embryolast) Implants complete w/n 7-10 days
Zygote (fertilized ovum; about 24-48 hrs, divides; cleavage divides, travels to the uterus
III.a ORIGIN OF BODY TISSUE
Tissue Layer ECTODERM Mesoderm Endoderm Body Portion Formed Nervous system, mucus membranes, anus & mouth Connective Tissue, Reproductive, circulatory & upper Urinary system, bones, cartillage lining of the GI tract, Respiratory Tract, bladder & urethra
MULTIPLE PREGNANCIES Double ovum Single Ovum Dizygotic/fraternal twins Monozygotic/identical twins Ova from same or different ovaries union of a single ovum & a single sperm Same or different sex same sex one placenta
2 placentas but maybe fused 2 chorions & 2 amnions Genetics: Phenotype: Genotype: Karyotype: Serotype:
one chorion & 2 amnions
Individual’s outward appearance Individuals Genetic Make up Pictorial analysis of individual’s chromosomes antigenic character “ABO”
Genetic Disorders: Autosomal Recessive Disorders: both men & women are at equal risk because the DEFECTIVE GENE is an AUTOSOME: one of 22 pairs of non-sex chromosomes. Offspring of each pregnancy has a 25% chance of being affected and 50% chance of being a carrier. Examples are: PKU ( phenylketenuria) , Tay - Sachs Disease, Cystic Fibrosis, Thallasemia, and Sickle Cell Anemia Autosomal Dominant: an affected offspring has an affected parent. Examples are: Huntinton’s Chorea and Marfan’s Syndrome (Arachnodactyly)
X-linked dominant/Recessive Disorders: abnormal gene is found on the X chromosome because men have only one X chromosome, they always express the disorder. Examples are: Hemophillia and Duchenne Muscular Dystrophy
IV. FETAL DEVELOPMENT
Figure 1- H2 Fetal Development
Heart sounds in the stethoscope Can be heard ( 17. With nails. • Placental transport of substances ( 5 weeks) • The fetus is 27-31 mm and weighs 2-4 grams • Fetus s markedly bent • Head is disproportionately large due to brain development • Centers of bone begin to ossify • Ganglionic cells (5th to 12th weeks) • Placenta and meconium are present. /21-25 weeks • • • • • 21-25 WEEKS… OLD MAN’s FACE Length 200-240 mm. Heart sounds are perceptible by auscultation. /17-20 weeks Lanugo covers entire body. Placenta dev’t. Liver is already pancreas functioning./9-12 wks 4 mos. Heartbeat can be heard in the fetoscope ( 18 weeks—20 weeks). • Head is erected. beginning of heart circulation. ears. • Rudimentary kidneys secrete urine. • Ganglionic cells SEX IS VISUALLY RECOGNIZABLE. • Placenta is complete. Eyebrows and scalp hair is present. Wt. nose appear Cardiovascular system functioning. genitourinary system. • External genitalia show definite characteristics. 32 .1 mo/ 4 weeks 2 mo/ 5-8 weeks 3 mos. • 94-140 mm length and weighs 97-200 gms. Brown Fats begin to form. bones. Heart is audible in a Doppler ( 11th week) Fetus swallows. • Fingers and toes are distinct. 495-910 gms. skin. Skeleton begins to develop. heart beginning to beat. • Heartbeat is present • Nasal septum and palate close • Fingerprints are set LANUGO APPEARS IN THE BODY • gms. with facial features CVS done (8 12 weeks) every organ present. lower limbs are well developed. If the mother is treated before 18 th week. and lungs are formed • Rudiments of eyes. /13-16 weeks Embryo is 4-5 mm length • Trophoblasts embedded in deciduas • Foundations for nervous system. In length and weighs approximately 260-460 • 5 mos. • Vernix caseosa covers skin. • • • Fetus is 150-190 mm.20 weeks) NOTE: There is a placental barrier to syphilis until the 18 th week of pregnancy. the baby will most likely not be affected. Head greatly enlarged • Average length is 50-55 mm and weighs 45 gms. Quickening felt by a mother. Skin appears wrinkled and pink to red. Kidneys able to secrete. • Fetal circulation is complete. REM begins Eyebrows and fingernails develop. 6 mos.
7 mos. /26-29 weeks
8 mos. /30-34 weeks
9 mos. /35-37 weeks
10 mos. / 38-40 weeks
VERNIX COVERS THE ENTIRE BODY. Has the ability to hear. Production of lung surfactants. Passive Antibody transfer ( placental immunoglobulin G) Sustained weight gain occurs. • Length 250-275; weight 910-1500 gms. • Skin red • Rhythmic breathing occurs • Pupillary membrane disappears from eyes. • Fetus often survives if born prematurely Brain develops rapidly. Lecithin- Sphingomyelin (L/S ratio is already 2:1) Brains fully developed. If born, neonate may survive. • Length 280-320 mm. weight 1700-2500 gms. • Toenails become visible • Steady weight gain occurs • Vigorous fetal movement occurs. LANUGO DISAPPEARS. Bones are fully developed. Aware of sounds outside the body. Assumes the delivery position. Increased chance of survival. • Length 330-360 mm. weight 2700-3400 gms. • Face and body has a loose wrinkled appearance because of subcutaneous fat deposit. • Body is usually lump and lanugo disappears • Nails reach fingertip edge • Amniotic fluid decreases. Increase Development. Sole of the foot have already creases. Good chance of survival. • Length 360 mm.; Weight 3400-3600 gms. • Skin is smooth, chest is prominent • Eyes are uniformly slate colored • Bones of skull are ossified and are nearly together at sutures. Testes are in scrotum. Optimum Time for survival. Full term. Lightening is present.
V. Fetal Circulation
As early as 3rd week of intra-uterine life, fetal blood is already is circulating, specifically there is already exchange of nutrients with the maternal circulation in the chorionic villi. > Arteries carry UNOXYGENATED BLOOD. VEINS carry OXYGENATED BLOOD. > Fetal Circulation Bypass: Why: DUE TO NON-FUNCTIONING LUNGS: ----- Ductus arteriousus (between pulmonary artery & Aorta, OPENS AT BIRTH & CLOSES 24 –48 hours after delivery.) It CONTAINS a mixture of arterial & venous blood. ----- Foramen Ovale : between right & left atrium DUE TO NON-FUNCTIONING LIVER: ----- Ductus Venosus (by pass the liver, closes at birth; an umbilical vein that carries High oxygen from the placenta.
Figure I. i Changes in Fetal circulation (Prenatal to Post natal Circulation)
V.a Measuring Age of Gestation
Genetic Defects: cystic fibrosis. McDonalds Formula (age of gestation) Fundic ht in cm x 2 divided by 7 = AOG in months 21 cm x2 7 = 24 weeks 3. J Fundic Height 1.=months (squared) 6 . Performed between the 8th – 11th weeks of gestation.Figure I. Can detect the ff. 1996 2. trisomy 21. enzyme. DNA & biochemical abnormalities. sample obtained by slender catheter passed through cervix to implantation site. Fetal Length (Haase’s Rule) 1 – 5 months . a. 36 . Estimated Date of Confinement (EDC) March 20. Maternal & Fetal Diagnostic tests CHORIONIC VILLI SAMPLING Earliest test possible on fetal cells. 1995 Minus-3 months +7 days +1 year December 27. Tay Sachs. Chorionic Villi Sampling: removal of a small piece of Chorionic villi sampling to detect the ff: fetal chromosome.10 months = months x 5 VI. sickle cell anemia.
Spontaneous abortion 5. The patient does not require complete bed rest after CVS---SHE SHOULD REFRAIN FROM SEXUAL INTERCOURSE AND PHYSICAL ACTIVITY FOR 48 hours. Use adjunct to amniocentesis. Risk of Abortion 2. useful early in pregnancy to identify gestational sacs. placenta & uterine cavities 37 . growth patterns. Premature rupture of the membranes After an Rh-negative patient undergoes amniocentesis or CVS.Non-invasive procedure with high frequency sound waves to obtain outline of the fetus. uterine anomalies and adnexal masses. (16th. anomalies. safe for fetus (no ionizing radiation) Ultrasound: done 18-40 weeks for fetal abnormalities. Most common indication: advance maternal age: increases risk of chromosomal damage from aging of oocyte.thallasemia. Great est Advantage over Amniocentesis: PERFORMED DURING THE FIRST TRIMESTER. Laboratory results are obtained in 1 .7 days compared to 20-28 days for an amniocentesis. . No known risk THE BEST TEST FOR ECTOPIC PREGNANCIES . ULTRASOUND Use of sound and returning echo patterns to identify intrabody structures. Duchenne muscular dystrophy & hemophilia. later uses include assessment of fetal viability.20th week of gestation). an antigen antibody immunologic reaction that sometimes occurs when an Rh negative mother carries an Rh + fetus. Embryo-fetal/placental damage 4. the nurse should administer Rh (D) immune globulin (RhoGAM). Disadvantages: 1. fluid volume. Infection 3. to prevent Rh sesnsitization. A small amount of spotting is normal for the 1st 24-48 hours.
Typically performed on the 3rd trimester to assess LECITHINSPHINGOMYELIN RATIO IN THE 38 . sex of fetus. gestational age. anesthesia isn't given for amniocentesis. The client should be supine during the procedure. Procedure: Ultrasound 1st: the rationale: to locate the Placenta. No known risk AMNIOCENTESIS Location and aspiration of amniotic fluid for examination. . afterward. Vital signs are assessed every 15 minutes.and to confirm gestational age & EDD. Amniocentesis: invasive procedure for amniotic fluid analysis. promote venous return.V. COMMON METHOD IN LOCATING THE PRECISE POSITION OF THE FETUS & PLACENTA BEFORE AMNIOCENTESIS. she should be placed on her left side to avoid supine hypotension. b. I. The patient MUST EMPTY THE BLADDER TO REDUCE THE SIZE OF THE BLADDER. levels of alpha-fetoprotein and other chemicals indicative of neural tube defects and inborn error of metabolism. possible after the 14th week when sufficient amounts are present. used to identify chromosomal aberration. RH factor. and ensure adequate cardiac output. & fetal lung maturity. NEEDS A FULL BLADDER TO OBTAIN A BETTER IMAGE (drink a full glass every 15 minutes beginning an hour & half the procedure) .
Maternal hemorrhage 2. NORMAL L/S RATIO (lecithin/sphingomyelin): 2:1 = normal fetal lung maturity ratio Most important factor affecting Amniocentesis: NEEDLE INSERTION-because of the risk of puncture or damage to the placenta. the patient is monitored for uterine contractions. bladder & uterine arteries. which is commonly delayed in a diabetic client. Cesarean Delivery should not be done. Maternal serum screens for open neural tube defects. Infection 3. not used in early pregnancy to avoid possibility of causing damage to fetus and mother. PLACE A FOLDED TOWEL ON HER RIGHT BUTTOCKS TO TIP HER SLIGHTLY TO THE LEFT & MOVE THE UTERUS OFF THE VENA CAVA TO PREVENT SUPINE HYPOTENSION SYNDROME. abruptio placenta 5. During this period. leakage of fluid. umbilical cord. Disadvantages: Risk for: 1. unless the fetal lungs are matured. withdrawing amniotic fluid. Rh immunization 4. Amniotic fluid embolism CALL THE PHYSICIAN FOR THE FF: Chills. It is a glucoprote in produced by ALPHA-FETOPROTEIN SCREENING 39 . the patient isn’t ambulated.AMNIOTIC FLUID (this ratio indicates fetal lung maturity). decrease fetal movement or uterine contractions. ABDOMINAL PREP IS DONE. Position: Supine. fetus. needle insertion in a 20-22 gauge spinal needle. fetal heart rate changes and leakage of amniotic fluid from the puncture site. fever. then. X-RAY Can be used late in pregnancy (after ossification of fetal bones) to confirm position and presentation. • After amniocentesis.
Phosphatidyl Glycerol (PG): when present in the amniotic fluid. Found in amniotic fluid after 35 weeks. Cord blood aspirated and tested. uses amniotic fluid. ratio is 2:1 indicative of mature levels. drops after 36 weeks gestation. body movements.L/S RATIO PHOSPHATIDYL GLCEROL fetal yolk sac. At 35-36 weeks. Teach mother to count 2-3 times daily. GI tract and liver. FETAL MOVEMENT COUNT PERCUTANEOUS UMBILICAL BLOOD SAMPLING BIOPHYSICAL PROFILE 40 . muscle tone. Alpha Fetoprotein: PRINCIPAL SCREENING TEST DOR THE DETECTION OF NEURAL TUBE DEFECTS (spina bifida. reactive heart rate and amniotic fluid volume. mother should notify care giver immediately of abrupt change or no movement. Used in second and third trimesters. anencephaly & the absence of ventral abdominal wall. A collection of data on fetal breathing movements. toxemia & fetal distress & Rh immunization. CREATININE LEVEL BILIRUBIN Estimates fetal renal maturity and function. Test done between 16 and 18 weeks gestation. LOW: chromosomal defects (Downs syndrome) HIGH: (greater than 10 mg/dl) Neural tube defects. uses amniotic fluid. The yellow color is the result of fetal anemia and bilirubin. Uses ultrasound to locate umbilical cord. or RDS will not occur. hydrocephalus-can be reduced through increase folic acid-0. it contributes to increased reliability of fetal lung maturity testing.4 mg/day in the 1st trimester) > Maternal blood sampling between 16-20 weeks. 3060 minutes each time. In conjunction with the L/S ratio. Level-high early in pregnancy. should feel 5-6 movements per counting time. Maybe done in laboratory. Uses amniotic fluid to ascertain fetal lung maturity through measurement of presence and amounts of the lung surfactants lecithin and sphingomyelin. premature delivery. it can be predicted that respiratory distresss will not occur.
Non-Stress Test – accelerations in heart rate accompany normal fetal movement. Reactive (normal): indicates a fetal fetus Greater than 15 beats per minute. non-invasive Tocodynamometer records fetal movements and Doppler ultrasound measures . Contraindicated for history of PRE-TERM LABOR. Oxytocin Challenge test Indications: ALL PREGNANCIES AFTER 28 WEEKS WITH HIGH RISK CLIENTS. NOTE: COMMONLY PERFORMED ON DIABETIC PATIENTS BECAUSE OF THE INCREASE RISK FOR STILL BIRTH.2 or more FHR accelerations of 15 seconds over a 20 minutes interval and return of FHR to normal baseline. PREPARATION: • Woman in semi-Fowler’s or side-lying position. given after the 32nd week. The doctor will order an Oxytocin Test AFTER the patient has non-reactive test.occur with fetal movement in a 10 or 20 minute period. evaluates fetal heart rate in response to fetal movement especially for: Maternal Problems such as chronic hypertension. TYPES: a. Contraction Stress Test (CST) – based on the principle that healthy fetus can withstand decreased oxygen during contraction but compromised fetus cannot. Indicated for: assess placental function & oxygenation. PREPARATION: Patient should eat snacks. Interpretations: POSITIVE RESULT: Late decelerations with at least 50% of contractions. diabetes and Pre-eclampsia. B. Non-Reactive (Abnormal): No fetal movement occurs or there is short-term fetal heart rate variability (less than 6 beats per minute). FAVORABLE RESULTS: . the monitor records a mark at each point of fetal movement. RESULTS: 1. which may necessitate to C-section. Mammary stimulation Test or Breast Stimulation Exam or Nipple Stimulated CST – non-invasive b. • Monitor for post-test labor onset. 2.ELECTRONIC MONITORING A. Potential risks to the fetus. Position: Semi-Fowlers or left lateral positions the mother may ask tom press the button every time she feels fetal movements. Fetal well-being.Observation of fetal heart rate related to fetal movement. Response of the fetus to induced uterine contractions as an INDICATOR OF UTEROPLACENTAL & FETAL PHYSIOLOGICAL INTEGRITY. 41 . fetal well being.
Normal: “Negative Window”: (-) LATE DECELERATIONS OF FHR with three contractions a 10m minute interval Normal and known as “Negative window Laboratory Studies 1. Instruct the client to cough to cause the fluid to leak from the uterus if the membranes are ruptured. Fetal tone 3. The Betke-Kleihauer test is a test that determines if a greater than usual fetal – maternal blood mix occurred. It is also used in Rh incompatibility cases to determine if another dose of Rhogam is needed Fern Test: determine the presence of Amniotic Fluid leakage. Types: 1.5.determines presence of maternal antibodies attached to the baby’s cell.2 – 7.5 Amniotic fluid: PH: 7. Biophysical Profile : surveillance of fetal well being base on 5 categories: 1. Abnormal: “Positive Window”: (+) LATE DECELERATIONS OF FHR with three contractions a 10 minute interval. Rh (D) & D negative who hasn’t formed antibodies should receive Rhogam at 28 weeks gestation or after 72 hours after delivery. NEGATIVE RESULTS: No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in 10 minutes period.5. Position: Dorsal Lithotomy. Indirect Coomb’s Test: women who have Rh negative have this test done to determine if they have antibodies to the factor present. to discover presence of antibodies present in Rh-negative mother’s blood. > Test will confirm the diagnosis for Hemolytic Disease in the Newborn. Nitrazine Test: use of nitrazin strip to detect the presence of amniotic fluid.Abnormal and known as “Positive window”. Collect a 24-hour urine specimen or serum blood levels. Fetal breath mov’t 2. Mothers reveal antibodies as a result of previous transfusion or pregnancy. Indicates Uteroplacental Insufficiency.5 (turns the yellow Nitrazine blue gray. Using a sterile technique. High Estriol: Good placental function Low Estriol: Fetal hypoxia Estriol: estrogenic hormone. blue green – Ruptured Membranes) Kicks count: fetal movement counting mother sits quietly on the LEFT SIDE for 1 hour after meals & count fetal kicks for 30 minutes. synthesized by the placenta & adrenal gland of the fetus which secreted by the ovaries Rh Incompatibility Test: Purpose: a. Estriol excretion: measures placental functioning through urine test. Amniotic fluid 42 . Repeated 28 weeks pregnancy. Vaginal Secretions: PH: 4. 2. a specimen is obtained from the external os of the cervix & vaginal pool. Direct Coomb’s test: tests for newborns cord blood. Notify the physician or health care provider if FEWER THAN 3 KICKS.
which occurs in pregnancy POSITIVE Auscultation of fetal heart by week 8 Ultrasound imaging of fetal heart motion by week 7 Ultrasound confirmation of gestational sac by week 6 Ultrasound: 6 weeks can Palpating fetal contours auscultate the fetal heart. VIII. Placental Grade Interpretation: Fetal score of 8 – 10: normal fetal well-being Fetal score of 4 – 6: fetal distress VII. CO2 is passed through the cervix to the uterus. Sims Huhner Test (Post Coital Test): within 1 –2 days. THREE PREGNANCY SIGNS & SYMPTOMS PRESUMPTIVE Amenorrhea Nausea/Vomiting Breast sensitivity and increased size Fatigue Abdominal enlargement Skin pigmentation changes (Melasma chloasma. gas will pass through the fimbriated end of the fallopian tubes. e. PROBABLE Pregnancy test (presence of HCG) Softening of the uterine isthmus (Hegar’s sign) Cervical softening (Goodell’s sign) Goodell’s sign is a softening of the cervix. > If patent. Purpose: test for incompatibility of sperms with cervical mucus. linea nigra. detect the recurrence of Cancer. > A test to detect infertility caused by a defect in the tube. Papanicolau Test: cytologic test for cancer > Detect precancerous lesions &. Result: Negative: mahogany brown stain Positive: no staining b.a brown line running from the umbilicus to the symphysis pubis Stretch marks will eventually fade to a silvery white color. 1-2 days is the best time to evaluate fertility because there is increase estrogen. a specimen of seminal fluid from the posterior fornix & cervical canal is aspirated 2 –4 hours after coitus.ABUNDANT CERVICAL MUCUS. Fetal heart reactivity 5. d. the • Braxto 43 . . which is usually related to Past Infection.4. Braxton-Hicks contractions Ballotment: bouncing of the fetus in theFetal movements palpated by amniotic fluid against the examiners hand.determines tubal patency of the fallopian tubes. Hysterosalphingogram : COMPLETE EVALUATION OF ALL PELVIC ORGANS IN FEMALES > EVALUATES TUBAL PATENCY & PROBLEMS IN FERTILITY. During the 16 provider by week 20. candidates are women of 20 years old & above & sexually active women. > Cervix is tainted with tincture of iodine. Rubins Test. c. Schiller Test: indicated for cancer.increases sperm survival. Other Gynecological Procedures a. > If the tubes are patent. the dye can be visualized passing out the fimbtriated end & of the fallopian tubes. will give a sensation of fullness & spasmodic pains due to irritation from the gas. color change in the cervix is noted.
IX. Discomforts in Pregnancy Discomfort Nausea & Vomiting Urinary Frequency Breast tenderness & Engorgement Heartburn Trimester ends on the 1st trimester ends on the 1st trimester May start on the 3rd trimester also all trimester phases 2nd . shorter intervals > Avoid fatty foods & Na Bicarbonate > Drink milk between meals > Increase water (8-12 glasses) .3rd Nursing Measure > dry crackers & eat small frequent feedings Kegel’s exercise. The most objective sign of pregnancy is fetal movement felt by the examiner.nursing intervention > Elevate the legs with a pillow (Prevention) Muscle & Leg cramps 3rd 44 . Chadwick’s sign is a bluish coloring of the vaginal mucosal that occurs as early as 6 weeks gestation. darker areola. Rationale: due to increase vascularity & blood vessel engorgement.but it is highly unlikely that they will completely disappear. > wear supportive well fitting bra > avoid soap: to prevent drying > smaller meals. Detectable 10 days after the missed period . Increase size of the uterus * + Pregnancy Test > Secretion of HCG in the urine (Frog Test). Braxton Hicks contractions increase in frequency and intensity between 32 and 35 weeks.increase in fullness. Breast changes. The fetal heartbeat typically can be heard and fetal rebound is possible between 18 and 22 weeks. *Quickening: first fetal mov’t. The fetal outline becomes palpable and the fetus is highly mobile between 28 and 31 weeks. *Urinary Frequency * Melasma .to minimize regurgitation > leg extension & feet dorsiflexion relief. n Hicks Contractions: painless contractions felt for 20-30 minutes occurs on the 16th week.
NOT KNEE HIGH HOSE > Wear low heeled shoes. Prevention is more desirable than treatment. > due to Iron Deficiency Anemia The diagnosis of iron-deficiency anemia is made on the basis of a hemoglobin concentration value of 10 g/dl blood or less and a hematocrit value of 30% or less. X. Hygiene. Laxatives and suppositories should not be used routinely in pregnancy.Varicosities Bach aches Supine Hypotensive Syndrome Leukorrhea Fatigue 3rd 3rd 3rd 3rd 2nd Wear supportive hose. Sitting & Pelvic Rocking > Left Lateral side lying position: relieve inferior vena cava syndrome > Avoid Douche. PSYCHOLOGICAL CHANGES IN PREGNANCY TRIMESTER PSYCHOLOGIC CHANGES TASK 45 . Frequent rest periods & give dark leafy vegetables Constipation 2n--3rd Prevention: High fiber Intervention: Increase Fluid NOTE: Bulk and fluid help increase peristalsis.
psychosocial tasks include mother-image development. alterations in body self-image and anxiety about the coming labor and delivery. Alternate feelings of emotional well-being and liability. women generally feels their best. Preparing for parenthood. Renewed fears and tensions about labor. PATERNAL ADAPATATIONS / REACTIONS TO PREGNANCY COUVADE SYNDROME: identification of the mother. Third Feelings of awkwardness and clumsiness. Spurt of energy during last month. “I AM A MOTHER” During the third trimester. ambivalence & anxiety about the role change JEALOUSY STAGE: increase interest in mothers care. The emotions and fears that are usually felt during the third trimester are feelings of “ugliness”. Adjustment to change in body image. Second The second trimester of pregnancy. and death. 46 . Possible decrease in sex drive. a key psychosocial task is to overcome fears the woman may have about the unknown. …Accept the biological fact of pregnancy Second Trimester: ACCEPTANCE---of the identification of motherhood & awareness & interest in the fetus.First The benefits of drug therapy outweigh the risks to the patient’s nausea is to control in a first trimester patient’s nausea. fears & fantasies & dreams about labor I am going to be a mother…Prepare realistically for birth & parenting B. A. and prenatal bonding.about pregnancy: pregnant woman focus only to self. SELF-CONCEPT CHANGE: active involvement in the fears & death of the fetus. coping with body image and sexuality changes. Possible increase in sex. labor pain. During the second trimester. I am going to have a baby… Accept the growing fetus as distinct from self & as person to care for Third Trimester: EMOTIONAL LABILITY. the mother copes with the common discomforts and changes Accepting the baby “A BABY IS GROWING INSIDE ME” . Acceptance of pregnancy. loss of control.assuming already the mother. Ambivalence Fear Fantasies about motherhood and about having a ‘dream child’. . MATERNAL ADAPTATIONS DURING PREGNANCY / with BIOLOGICAL TASKS OF PREGNANCY First Trimester: AMBIVALENCE. I am pregnant. loss of self-esteem. Accepting the pregnancy “I AM PREGNANT” During the first trimester.
Complete 4. Avoid coitus for 2 weeks following last evidence of bleeding Rhogam indicated when a young patient has a threatened abortion in the first trimester and a laboratory studies reveal an Rh negative and the husband is Rh positive Save tissue fragments Continuous monitoring Dilatation & Curettage. Abortion -termination of pregnancy before the fetus is viable (20 weeks or a weight of 500 g) ABORTION Therapeutic Spontaneous Inevitable Threatened Complete Incomplete Missed Habitual Fig. Sedation. absence of uterine growth 47 . Use of oxytocin: Oxytocin nasal spray should be administered while the client is sitting with her head in a vertical position. abortive process is going on Products of conception are totally expelled Some fragments are retained inside the uterine cavity Bleeding and cervical dilation Minimal bleeding Profuse bleeding 5. Missed Retention of the products of conception after fetal death Intermittent bleeding.SECTION III ANTEPARTAL COMPLICATIONS A. Restrictive activity. 4. A nasal preparation must not be administered with the client lying down or the head tilted back because this could cause aspiration. Inevitable 3.4 T y p e s o f A b o r t i o n TYPES 1. Incomplete Threatened loss that can be prevented. Threatened DEFINITION The continuation of the pregnancy is in doubt S/S Bleeding or spotting closed cervix NURSING INTERVENTION Bedrest. Evacuation Evacuation. D & C 2.
blood type and group Management Monitor amount of bleeding Assess vital signs Assess abdominal pain Blood transfusion Surgery: Salpingostomy Administer Rhogam for Rh (-) client 48 . Ectopic Pregnancy A. Shock may develop from blood loss.V.Mass in the adnexal or cul-desac . all perineal pads must be inspected for the products of conception. Fluid replacement is necessary because of blood loss B.Habitual / Recurrent 3 spontaneous abortions occurring successively Provide IV. Signs and Symptoms -Vaginal Bleeding -Knife-like abdominal pain -Referred pain on the right shoulder -Symptoms of Shock: decreased BP increased RR. dark vaginal bleeding . and large quantities of I. This is the number 1 complication. psychological support NOTE:Because spontaneous abortion is threatening. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. with cramping and tenderness . Count perineal pads. Causes -Narrowing of tube -Pelvic infection -Endometriosis -Smoking -History of IUD usage . Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity.Profound shock if rupture occurs Diagnostic Tests -Culdocentesis -Culdoscopy -Radioimmunoassay of elevated serum qualitative -Beta-HCG -Abdominal Ultrasound -Blood samples of Hgb and Hct. fast but thready pulse. -Pelvic pressure of pelvic fullness -Cullen’s sign -Pain unilaterally. Description: A pregnancy that occurs in another than uterine site.6.Slight. with implantation usually occurring in fallopian tubes A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Monitor bleeding.
Hyper . Excessive N/V 3. C. Incomplete/ partial. Delay childbearing plans for a year 5. The #1 Complication is Choriocarcinoma The Three H of H-mole 1. X-ray of the abdomen MANAGEMENT 1. (+) Pregnancy test 5. Low socioeconomic status 2. Abdominal cramps 7. Possible PIH 6. Rapid enlargement of the uterus 4. Complete/ classical parts of the villi are affected 2. Perineal pad counts 6. Instruct the couple to have VAGINAL REST ( no sex) for 1 year.some parts are normal MANIFESTATIONS 1.000 IU DIAGNOSTIC TESTS 1. increase incidence for piH PREDISPOSING FACTORS 1. Women of asian heritage TYPES 1. characterized by the proliferation and degeneration of the chorionic or trophoblastic villi. The #1 Complication of H-mole is choriocarcinoma 49 . Monitor HCG levels 4. Intake of Clomid (Clomiphene Citrate) 4. HCG titer determination 2. Normal level: 400.emesis gravidarum 2. Elevated HCG titer: 1-2 million IU. Molar evacuation / D&C 2. Ultrasound 3. Women below 18 or above 35 3. A patient with Hydatidiform mole has a positive signs of pregnancy but is not pregnant. Vaginal bleeding 2. Hydatidiform mole / Trophoblastic Disease / Molar Disease - Gestational trophoblastic neoplasm that arise from the chorion.The #1 Complication of Ectopic Pregnancy is Hemorrhagic Shock. Absent FHR 8. Chemotherapy 3. increase Hcg 3.
Traumatic injuries to the cervix.Painless dilatation 9. diabetes in pregnancy. Habitual abortion 5.Ultrasound 11.D. birth defects. Congenital anomaly 2. Repeated dilatation of the cervix.Cervical Cerclage. maternal DES ( Diethylstilbestrol) Exposure.Sterility. Birth of dead/non-viable fetus 10. Ectopic pregnancy.PROM 3. The cervix dilates painlessly in the second trimester of pregnancy. Pre-term labor 6. rupture of the cervix premature delivery.Painless premature dilatation of the cervix (usually in the 16th to 20th week) INCOMPETENT CERVIX Figure 19 INCOMPETENT CERVIX Synonyms Predisposing/Contributing Factors: Dysfunctional cervix 1. pelvic bleeding and infection.Ultrasonography 12. Uterine anomaly 4. Pressure or heaviness on the lower abdomen. #1 Hemorrhage. Initial Signs Late signs: Cardinal/Pathognomonic/major sign: 1. McDonald Cerclage 13. Bloody show 2. Incompetent cervix . Trauma to the cervix (surgery / birth) 3. viruses and pregnancy diseases. Show (a pink-stained vaginal discharge) 7. #1 Sign: Rupture of membranes and discharge of amniotic fluid 8. HPN Side lying position Prone position Suction Cervical Incompetence Pre-op: Encourage patient to maintain bed rest Post-op: Check for excessive vaginal discharge and Screening or initial diagnostic test: Conformity test: Best major surgery: Possible surgical complication: Disease complication Best position before and after surgery Best side equipment Nursing Diagnosis Nursing Intervention 50 .
Bed rest in trendelenburg position 2. Administer tocolytic medications as ordered Eg. Ritodrine Hydrochloride (Yutopar): Terbutaline sulfate (Brethine): Magnesium Sulfate Hydroxyzine hydrochloride (Vistaril) is a common drug ordered to counteract the effect of terbutaline (Brethine) 3. insulin-dependent diabetic is at risk for sudden hypoglycemia because insulin needs and metabolism are affected b pregnancy. Description of Diabetes in Pregnancy 1.severe pain. Maternal glucose crosses the placenta but insulin does not During the first trimester. Maternal glucose is consumed by fetus o Late in pregnancy: A. Surgery: Cervical Cerclage a. when the episiotomy has healed and the lochia had stopped . b. Maternal and Child Nursing.Monitor V/S and report HPN Monitor FHR Limit activities Observe for Ruptured BOW Avoid vaginal douche Avoid coitus (Pillitteri. maternal insulin needs decrease The fetus produces its own insulin and pulls glucose from the mother. making sudden hypoglycemic episodes more common for diabetics. which predisposes the mother to hypoglycemic reactions 51 .391-93) E. 1. p. • Changes in the glucose-insulin mechanism: o Early in pregnancy: A. Shirodkar-Barter Technique ( internal os) permanent suture: subsequent delivery by C/S. Increase production of insulin B. Mc Donald Procedure ( external os)-suture removed at term with vaginal delivery Usually 4-6 weeks after vaginal delivery is the safe period for a patient to resume sexual activity. DIABETES MELLITUS • Gestational diabetes mellitus (pregnancy induced) A pregnant. 3. Mother develops insulin resistance B. 2. The presence of placental insulinase breaks down insulin rapidly B.
increases in placental hormones cause an insulin-resistant state. tingling or numbness in hands 20. Recurrent urinary tract infections and vaginal yeast infections 7. respiratory distress syndrome. Diabetes mellitus is more difficult to control during pregnancy & occurs during the second or third NOTE: The greatest incidence of insulin coma during pregnancy occurs during the second and the third months. Fatigue. weakness. 3-P’s: Polyuria. Fetus large for gestational age 19. Diabetes during Pregnancy 16. The newborn infant of a diabetic mother is subject to hypoglycemia. 50 gms oral glucose challenge test 22. and vomiting excessive thirst. Stillborn and neonatal mortality rates are higher in pregnancies of a diabetic woman 5. 15. Frequent urination 6. decrease urination 21. Signs of pregnancy-induced hypertension 9. and congenital anomalies. Premature delivery is more frequent. GESTATIONAL DIABETES GESTATIONAL DIABETES Definition A type of Diabetes where only pregnant women gets where her blood sugar rate elevates but never had a high blood sugar rate before pregnancy. FBS more than 140 mg/dl 18. Polyhydramnios 10. sudden vision changes. 3. Progesterone& Corticosteroids • Maternal age more than 35 • Previous macrosomic infant • Previous unexplained stillbirth • Previous pregnancy with GDM • Family history of DM • Obesity • Hypertension 17. Hyperglycemia develops during pregnancy because of the secretion of placenta hormones such as Prolactin. hyperbilirubinemia.4. the incidence of the diabetic coma during pregnancy occurs around the sixth months. nausea. Glycosuria and ketonuria 8. Weightless 4. Polydipsia and Polyphagia MATERNAL SIGNS & SYMPTOMS: 1. The newborn infant of a diabetic mother may be large in size but will have functions related to gestational age rather than size. fatigue. During the second and third trimesters.hour glucose tolerance test will be performed to confirm diabetes mellitus Synonyms Predisposing/Contributing Factors Initial Signs Late signs Cardinal/Pathognomenic/major sign Screening or initial diagnostic test Confirmative test 52 . Weight loss. requiring an increase in the client's insulin dose trimester. Hunger 3.Excessive thirst 2. Blurred vision 5.
Screen clients between the 24th and 28th weeks of pregnancy 2. Best diet for the disease: Disease complication Best side equipment Best drug Nature of the drug Nursing Diagnosis Nursing Intervention Glucometer Insulin Equipment #1 Eternal Electronic Fetal Heart Rate monitoring Insulin therapy ( don’t use Oral hypoglycemics. it decreases the insulin requirements for insulin-independent clients. Well-balanced Caloric Diet 26. it leads to an increased caloric demand. neural tube defects. .Best diet 23. macrosomia. 27. Calories in diet should consist of 50% to 60% carbohydrates. Maternal Complications: PIH. stillbirth. 12% to 20% protein. food and physical activity Potential heath care deficit related to physical improvements or social factors. and 20% to 30% fat NOTE: Because insulin does not pass into the breast milk. Placental disorders. Breastfeeding is encouraged. Breastfeeding does not increase the risk of maternal infection. they are Teratogenic) Insulin #1 High Risk for fluid volume deficit related to polyuria and dehydration Imbalanced nutrition related to imbalanced of insulin. 3. Infants of diabetic mothers often display jitteriness in response to hypoglycemia after birth 25. Fetal Diabetic Complications: • Macrosomia • Pre-eclampsia • Hydramnios • Congenital anomalies NOTE: The incidence of congenital anomalies among infants of diabetic pregnancies is three to four times higher than that in general population and is related to the high maternal glucose levels during the third to sixth gestational weeks. 53 . Strict Diabetic Diet 24.Glycosolated Hemoglobin less than 8% 23. Calories in diet should consist of 50% to 60% carbohydrates. Prenatal visits bimonthly for 6 months and weekly thereafter.. breastfeeding is not contraindicated for the mother with diabetes. 12% to 20% protein. MANAGEMENT 1.
No symptoms of cardiac insufficiency. Class I: no limitation of activities. Asymptomatic at rest. Monitor for signs of infection or post hemorrhage 6. The preferred method of administration if insulin is required during labor is intravenous OTHER IMPORTANT MANAGEMENT: • Urine testing • Blood glucose determination • Insulin administration • Dietary management • Exercise • Fetal surveillance: (* Non-stress test * contraction stress test * amniocentesis) (Pillitteri. Ordinary activities causes fatigue. less than ordinary activities causes discomforts d. Class IV: unable to perform any physical activity without discomfort. Maternal and Child Nursing. MANAGEMENT • Goal is to reduce workload of heart • Promote rest • Promote a healthy diet • Educate regarding medication • Educate regarding avoidance of infection • Promote reduction of physiologic stress PREGNANCY INDUCED HYPERTENSION (TOXEMIA OF PREGNANCY) NAME OF THE PRE-ECLAMPSIA ECLAMPSIA 54 . p. CARDIAC DISEASE • • • • CLASSIFICATION Class I Asymptomatic Class II Asymptomatic at rest. palpitations and dyspnea c.and 20% to 30% fat 4. symptomatic at rest EFFECTS • Retarded growth • Fetal distress To relieve fetal distress let the patient lie on her side • Premature labor You don’t have to notify the physician if the patient complains of a “fluttering” sensation in her chest because of taking terbutaline (Brethine) SQ for premature contractions because it is a common side effect unless vital signs indicate stress a. b.349-356) F. Class II: slight limitation of activity. Observe client closely for an insulin since a precipitous drop in insulin required is usual 5. If a pregnant diabetic is in labor. symptomatic with ordinary activity Class IV Symptomatic with all activity. her blood glucose should be monitored hourly. May have the symptoms during rest. symptomatic with heavy physical activity Class III Asymptomatic at rest. comfortable at rest. Class II: marked limitation of activities.
2001.Phd B≥140/90 mmGh on at least two occasion ≥ 6 hours apart (The Lippincott Manual of Nursing Practice 7th ed.2 mg/dl.p.A.395) BP≥160/110 mmHg or diastolic pressure≥110 mmHg on two occasions at least 6 hours apart with the patient on bedrest. A.( Nurses’ 3 minutes clinical page 442 -443 Author: Gloria F Donnelly M. diabetes with vessel or renal involvement. poor calcium and magnesium intake (Pillitteri.2001. premonition that “something is happening”. epigastric pain or RUQ pain.p.2001. development of eclampsia (The Lippincott Manual of Nursing Practice. headache.000). or blurred vision). weight gain over 2 lbs per week in second trimester and 1 lb per wk.399. impaired liver function of unclear etiology. mild edema in upper extremities or face (Pillitteri. scotomata.p. 1999. third trimester. reflexes become hyperactive p. and essential hypertension. Initial Sign Late Sign Signs of Worsening PIH or Impending Seizures BP 160/110 mm Hg or above Epigastric pain Decreased urinary output Visual changes Headache 55 . a. women with heart disease. complications that require immediate attention because they can cause severe maternal and fetal consequences.p.1190) elevated serum creatinine > 1. 1999) During pregnancy. pulmonary edema or cyanosis.2001.395.. thrombocytopenia (platelet count <150.. blurred vision may be a danger sign of preeclampsia or eclampsia.1999.p.396) Oligauria ≤400 to 500 ml/24h.. urinary output less than 30 ml/h p. A.1190) proteinuria of 1-2+ on a random sample.1190) -Age-related concern: adolescents and primiparas over age 35 are at higher risk for preeclampsia. epigastric pain and nausea.DISEASE Synonym Predisposing / Contributing factors MILD SEVERE (PREGNANCY-INDUCED HYPERTENSION) -Primiparas younger than age 20 years or older than 40 years. preexisting vascular disease (The Lippincott Manual of Nursing Practice. women of color..4°C or 40ºC (103ºF to 104ºF) from increased cerebral edema. Signs and symptoms of severe pre-eclampsia. polyhydramnios. 1999 p. p. temperature rises sharply to 39. 7 th ed. cerebral or visual disturbances (altered level of consciousness.. 7th ed.1190) extreme edema in hands and face/”puffiness” (Pillitteri. 393) hydatidiform mole. multiple gestation.400 (Pillitteri.p. women from low socioeconomic background because of poor nutrition. proteinuria ≥5 b/24 h or 3+ to 4+ on qualitative assessment (urine dipstick) (The Lippincott Manual of nursing Practice 7th ed.
3. extensive perkipheral edema (Pillitteri. 2. NOTE: The patient with a diagnosis of PIH should be close to the nurses’ station because she requires close observation. Monitor input and output strictly. 2.. Evaluate NST to determine fetal status. increased respiratory rate). 56 . Instruct on the importance of reporting headaches. notify health care provider if urine output is <30 ml/h. 4. side rails should be padded and remain up to prevent injury if seizure occurs. (Pillitteri.394) • Fluid volume excess related to pathophysiologic changes of PIH and increased risk of fluid overload. notify primary care provider if urine output is < 30 ml/h. Monitor vital signs every hour. Maintaining Cardiac Output 1. and report signs of pulmonary edema (wheezing. dizziness. Monitor IV intake using a continuous infusion pump.p. Increase protein intake to replace protein lost through kidneys. 3. 4. Monitor input and output strictly. 1999. crackles. a. visual changes. preferably the left side to promote placental perfusion. 3. related to altered placental blood flow caused by vasospasm and thombosis. Fetal cardiac and cereral. Edema is significant only if hypertension and proteinuria or signs of multi-organ system involvement are present. increased pulse rate. Keep the environment quiet and as calm as possible. 2.cardiac involvement. Preventing Injury 1. • Decreased cardiac output related to decreased preload or antihypertensive therapy. Monitor hematocrit levels to evaluate intravascular fluid status. Promoting Adequate Tissue Perfusion 1. Auscultate breath sounds every 2 hours. 4. especially mean • Altered tissue perfusion. If patient is hospitalized. shortness of breath. Monitor maternal vital signs. Position on side. 1999. Control IV intake using a continuous infusion pump. 2. The patient also should be placed in a room with decreased stimuli.. Monitor fetal activity.p. • Risk for injury related to convulsions. and epigastric pain. Instruct to lie down on left side if symptoms are present. A.395) Cardinal / Pathognomonic/ Major Sign Nursing Diagnosis and Nursing Interventions Hypertension and proteinuria are the most significant. 5. 3. Maintaining Fluid Balance 1.
A. maternal/fetal death.RN p.1192-1193) Screening/Initial diagnostic test Confirmatory Test Blood pressure over 140/90.2001.. 2001. or increase of 30 mm systolic. Care of the Childbearing 57 .1190)s Administer antihypertensives such as hydralazine (Apresoline) as prescribed. the absence of reflexes is often the first indication of toxicity. to prevent a cerebrovascular accident Best tocolytic agent.A. 1999.1192) SEVERE PRECLAMPSIA: Lateral recumbent position (Pillitteri. Report oxygenation saturation rate of <90% to primary care provider.400) Infusion pump. 4. hepatic rupture (The Lippincott Manual of Nursing Practice. 1999.pp. References Pillitteri. respiration and urinary output are priority assessments during administration of magnesium sulfate therapy in patients with PIH.pp.. (Pillitteri.1999.p. of ≥ + 2 to primary care provider.p.p. acute renal failure. (Pillitterri. elevated serum BUN and creatinine. blood pressure changes meeting criteria for diagnosis (The Lippincott Manual of Nursing Practice.1192-1193) Mgnesium sulfate: 4-6 loading dose of 50% give IV over 15-30 mins followed by a maintenance dose (secondary infusion) of 1-4 g/h or IM injection or 10 g (5 g in each buttock) as a loading dose followed by 5 g every 4 hours (The Lippincott Manual of Nursing Practice.pp.7th ed. HELLP syndrome. moderate-sodium diet to compensate for the protein she is losing.A. 7th ed. 2001.397) ECLAMPSIA: to prevent aspiration. 2001. cerebrovascular accident..1999.. Assess edema status. pulse oximeter (The Lippincott Manual of Nursing Practice.blood pressure and respirations. turn the woman on her side to allow secretions to drain from her mouth. Respiratory depression occurs at levels of 10 to 15 mg/dl. 2001.. A. hypertensive crisis. Maternal and Child Health Nursing. anticonvulsant/eclampsia #1 Complication of MgSO4 is : Respiratory Depression Best Position Beside Equipment Best Drug Nature of the Drug PRIORITY DRUG ASSESSMENT: SIDE EFFECT • Reflexes. (Pillitteri. hemorrhage. and cardiac conduction problems occur at levels of 15 mg/dl and higher.pp. increased deep tendon reflexes and clonus. If the patient’s magnesium levels increase above the therapeutic range (4 to 8 mg/dl). This in turn causes the placenta to tear away from the uterine wall (abrupto placentae) (Mosby’s Comprehensive Revew of Nursing for NCLEX. Monitor oxygenation saturation levels with pulse oximetry.395) 24-hour urine for protein of 300 mg or greater. A.p.. Urinary output of less than 30ml/hour may result in the accumulation of toxic levels of magnesium. hypoglycemia.. 226) disseminated intravascular coagulation. blindness.. 1999.1190) The woman needs a moderate to high-protein.p.398) Best Diet Disease Complications • Abruptio placentae (Hypertension in PIH leads to vasopasm.7th ed. prematurity.7th ed. (The Lippincott Manual of Nursing Practice. 15 mm diastolic over pre-pregnancy level. and report pitting edema 5.7th ed. intrauterine growth restriction (IUGR) from decreased placental perfusion. antihypertensive. Reflexes often disappear at serum magnesium levels of 8 to 10 mg/dl.
Normal Response: Flexion of the arm at the elbow. Maintain the dorsiflexed position for a few seconds. Abnormal Response: (Positive Clonus Response) Rhythmic oscillations when the foot is dorsiflexed. usually caused by uterine atony.Lippincott Williams & Wilkins: Philadelphia. Proper Assessment of Abnormal Reflexes Assessment Patellar Reflexes Position the client with legs dangling over the edge of the examining table or lying on back with legs slightly. Form from Chorionic villi & deciduas basalis.. Placenta Previa (low implantation) Assessment: Abruptio Placenta (Premature separation) Assessment: 58 . a globular-shaped uterus. 3rd ed. and an increase in fundal height. further protrusion of the umbilical cord from the vagina. With cervical or vaginal laceration. the foot will drop to a plantar flexed position with no oscillations. Clonus Position the client with legs dangling over the edge of the examining table. Deciduas (meaning endometrial changes & growth) Functions: Main source of nourishment & acts a transfer organ for metabolic purposes for the fetus. Lippincott Williams & Wilkins: Philadelphia. Placental Problem Placental separation is characterized by a sudden gush or trickle of blood from the vagina. With postpartum hemorrhage. No rhythmic oscillation of jerking of the foot will be felt. 2001. USA. 7th ed. Normal Response: (Negative Clonus Response) Foot will remain steady in the dorsiflexed position. Support the leg with one hand and sharply dorsiflex the client’s foot with the other hand. The Lippincott Manual of Nursing Practice. weighs 400-600 grams. When released. the uterus isn't globular. Uterine involution can't begin until the placenta has been delivered. Similar oscillations will be noted when the foot drops to the plantar flexed position. Develops on the 3 rd month. then release the foot. Strike the patellar tendon just below the kneecap with the percussion hammer. BLEEDING DISORDERS AFFECTING THE PLACENTA Placenta: contains 20 cotyledons. USA. the nurse notes a consistent flow of bright red blood from the vagina.& Chidlrearing Family. G.
being . . Shock seeming to be out of proportion . Rigid (board like). Bed rest in wedge position too prevent supine hypotension . . . . Heavy bleeding w/c maybe partially\completely hidden . . relaxed uterus w/ normal tone Shock in proportion to observed blood loss Signs of fetal distress usually not present Predisposing Factors: * Multiparity* Advancing maternal age. Measure blood loss through perineal pad counts . Painless Heavy bleeding Soft. . Continually monitor fetal well. . Of pregnancy) Definition Predisposing Factor 59 . Severely painful . Continually monitor fetal well. Provide emotional support . * Multiple gestation* Alteration in the uterine structures Nursing Considerations: . NO vaginal exams .being Treat signs of shock and hemorrhage Provide emotional support Prepare for delivery PLACENTA PREVIA Figure 20 a PLACENTA PREVIA > Improperly implanted placenta in the lower uterine segment near or over the internal cervical os > Total: the internal os is entirely covered by the placenta when cervix is fully dilated > Marginal: only an edge of the placenta extends to the internal os > Low-lying placenta: implanted in the lower uterine segment but does not reach the os (Saunders page 299) > Maternal age > Parity (no. Client is hospitalized and put on bed rest . Caesarean delivery indicate .. tender uterus possible w/ contractions . . non tender. Signs of fetal distress Predisposing Factors: * Chronic Hypertensive disease* history of a short cord * Multigravida * trauma Nursing Considerations: .
(Saunders Comprehensive 2002 Edition. Additional pressure from an upright position may cause further tearing of the placenta from the uterine lining. #1hemorrhage. The hemoglobin and hematocrit levels are monitored and external electronic fetal heart rate monitoring is initiated. cerebral ischemia. #2shock. > Ultrasound for placenta localization NOTE: Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the third trimester unit a diagnosis is made and placenta previa is ruled out.Monitor maternal vital signs. p. Comprehensive p. preferably in a side-lying position. and fetal activity > Assess bleeding (amount and quality) > Monitor and treat signs of shock > Avoid vaginal examination if bleeding is occurring > Prepare for premature birth or cesarean section > Administer IV fluids as ordered > Administer iron supplements or blood transfusion as ordered (maintain hematocrit level) > Prepare to administer Rh immune globulin The patient with placenta previa should be maintained on bed rest. > Home monitoring with repeated ultrasounds may be possible with type Ilow lying > Control bleeding > Replace blood loss if excessive > Cesarean birth if necessary > Betamethasone is indicated to increase fetal lung maturity. (Mosby.418) > Ultrasonography to confirm the pressure of placenta previa. 304) > Left lateral position ABRUPTIO PLACENTAE Complication Therapeutic Interventions Nursing Diagnosis with Nursing Intervention BESTPOSITION Confirmatory Test Best Position 60 . > Depends on location of placenta. A diagnosis of placenta previa is made by ultrasound. 203) #1 NURSING DIAGNOSIS: Potential fluid volume deficit > Maintain bed rest > #1 Assessment . Ambulating would therefore be indicated for this patient. Performing a vaginal examination and applying internal scalp electrode could also cause the placenta to be further torn from the uterine lining. amount of bleeding and status of the fetus. maternal and fetal death (Nursing Alert p.> Previous uterine surgery Cardinal Manifestation > > > > > > Painless bleeding as early as 7 months (mild to hemorrhage) Soft uterus Abdominal fetal position of breech or transverse lie Uterine contractions Anemic anemia. #3 disseminated intravascular coagulation. renal failure. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus who is at risk for severe hypoxia. Digital examination of the cervix can lead to maternal and fetal hemorrhage. FHR.
Figure 21 Definition Synonyms Predisposing Factor ABRUPTIO PLACENTAE Premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered (Saunders page 299300) > Placental abruption > Premature separation of placenta > Maternal age > Parity > Previous abruptio placentae. multifetal gestation 61 .
It is also associated with physical and mechanical factors such as over distension of the uterus that occurs with multiple gestation or polyhydranions. such as hypertension. moist skin > Bloody amniotic fluid > Rising fundal height from blood trapped behind the placenta > Signs of shock > Manifestation of coagulopathy NOTE: Uterine tenderness accompanies placental abruption. In addition. p. smoking and alcohol or cocaine abuse. physical trauma. shock. especially with a central abruption and trapped blood behind the placenta. a short umbilical cord. p. fetal death(Nursing Alert p. maternal death. (Saunders Comprehensive 2002 Edition. The abdomen will feel hard and boardlike upon palpation as the blood penetrates the myometrium and causes uterine irritability. enlarged uterus > Board-like rigidity of abdomen (Cullen Sign) > Abnormal/absent fetal heart tones > Pallor > Cool.4) > Painful vaginal bleeding > Hypertonic to tetanic. Observation of the fetal monitoring often reveals increased uterine resting tone. disseminated intravascular coagulation. (Nursing Alert p.4) > Replacement of blood loss. renal failure. > May be complicated by hypertension or by an enlarged uterus that can’t contract sufficiently to seal off the torn vessels > Consequently. > With moderate or severe separation or maternal or fetal distress: emergency childbirth. 305) > Spontaneous rupture of blood vessels at the placental bed may due to lack of resiliency or to abnormal changes in uterine vasculature. and increased maternal age and parity are risk factors. possibly shearing off the placenta partially or completely.> Hypertension NOTE: Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation. (Saunders Comprehensive 2002 Edition. NOTE: The goal of management in abruption placentae is to control the hemorrhage and Pathophysiology Manifestation Complication Therapeutic Interventions 62 . bleeding continues unchecked. 304) > Hemorrhage. caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.
Delivery is the treatment of choic if the fetus is at term gestation or if the bleeding is moderate to severe and mother or fetus is in jeopardy. 204) #1 NURSING DIAGNOSIS: Risk for fluid volume deficit > #1 Assessment: Monitor and FHR > Assess for vaginal bleeding. short of breath and clammy when lying back for long periods of time in patients 6th month of pregnancy. compression of the viens in pelvis or legs The most likely cause of supine hypotension is feeling dizzy. 304) > With mild separation without fetal distress and in the presence of some cervical effacement and dilatation: induction of labor may be attempted >Oxygen if necessary > Maintenance of fluid and electrolytes balance. thus decreasing cardiac output. cyanosis Reduce renal perfection. orthopnea. abdominal pain. proxymal nocturnal dyspnea. (Saunders Comprehensive 2002 Edition. The cause of supine hypotension during pregnancy is the weight of the uterus compresses the inferior vena cava. (Mosby. Comprehensive p.reduced cordiac output. Supine Hypotensive Syndrome Thrombophlebitis NOTE: Contribute to clot formation motion include inactivity. decreasing the return of blood to the heart.Nursing Diagnosis with Intervention deliver the fetus as soon as possible. and increase in fundal height > Maintain bed rest > Administer oxygen as prescribed > Monitor and report any uterine activity > Administer IV fluid as prescribed > Monitor I & O > Administer blood products as prescribed > Monitor blood studies > Prepare for the delivery of the fetus as quickly as possible > Monitor for signs of disseminated intravascular coagulation in the post-partum period > Ultrasound detects retro-placental bleeding VENA CAVA SYNDROME Confirmatory Test Definition Synonym Predisposing factors The venous return to the heart is impaired by the weight of uterus. which lowers the blood pressure Fatique. hypoxia. p. Decrease glomerular filtration Initial sign Late Sign 63 .
respiratory distress. fatal distress FHT monitor NOTE: Above 160 or below 120 beats per minutes. Express a caring attitude Caesarian Section – note if cervix is incomplete deleted. caused by failure of the uterus to relax in an attempt to constrict blood vesicle and control bleeding > Respiratory failure. muscle relaxation. drug therapies. which reduce channel size. coal. Hypoallergenic Ionic diet Calcium increased Interruption of vena cava. Fetal PH below 7. and imagery to relieve discomfort. Food and fluid are withheld before invasive procedure is not resumed until the client is stable and free of nausea & vomiting. clammy Skin Maintain patient on bed rest to reduce Oxygen demands and risk for bleeding.5 Amniotomy: NOTE: Above keeping the significant other improved of the progress of care. Monitor prescribed medication given to preserve right Ventricular felling pressure and increase blood pressure Instruct patient in self – care activities Provide information about anti smoking strategies and allow patient time to return demonstration of treatment to the done at home Assess physical complaints matters of facts without emphasizing concern. Oxygen obtain equipment for external electronic fetal heart rate monitoring Oxygen with Cannula 64 . tachycardia. the fatal status would he the priority Altered tissue perfection related to decrease blood circulation Risk for altered Health maintenance related to insufficient knowledge of treatments. > Bleeding as a result of treatment NOTE: Observation of the fetal monitoring often reveal increase uterine rustling tone. Pressure. home care management and prevention of future infection Altered comfort related to maladaptive coping Closely monitor for shock and decreasing blood. Use deep – breathing.Cardinal sign Initial / Screening test Confirmatory test Nursing Diagnosis Nursing Intervention Best major Surgery Best dirt for pre-operative Best diet for Disease Possible Surgical Complication Complication of Disease Best position pre-operative Bed Side Equipment shock such as tachycardia NOTE: Caused by reduced cardiac output. Sims Position NOTE: Turning to the left side to shift right of the fetus off the inferior vena cava.
administer or teach selfadministration of hormones to suppress menstruation as prescribed. and pancreas NOTE: Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed. Monitor electrocardiogram and laboratory test for dysfunction of vital organs casued by ischemia – arrhythmias. 6. Avoid vasoconstrictive agents (systemic or topical). use topical hemostatic agents. Avoid dislodging costs. p.History of Disease Angina. and fibrin plugs may clog the microvasculature diffusely. fat embolism. #1 abruption placenta. Evaluate fluid status and bleeding by frequent measurement fo vital signs. Use tape cautiously. stomach. dyspnea. acute renal failure Minimizing Bleeding • Risk for injury related to 1. Change patient’s position frequently and perform ROM exercises. fractures. colon. This leads to widespread bleeding. pain. Maintain bed rest during bleeding episode. 304) Coolness and mottling of extremities. Monitor pad count/amount of saturation thrombocytopenia during menses. central venous pressure. (Saunders Comprehensive 2002 Edition. 5. 3. If internal bleeding is suspected. 4. anaphylaxis. and presence of hematuria are signs associated with the presence of DIC. abnormal bleeding Altered mental status. malignancies particularly of lung. eclampsia. burn. Administer blood products as ordered. trauma. sock. Keep patient warm 2. intake and output. and volume overload. • Altered tissue perfusion (all tissues) related to ischemia due to microthrombi formation Promoting Tissue Perfusion 1. abnormal arterial Initial Sign Late Sign Nursing Diagnosis & Intervention 65 . 7. hemolytic transfusion reaction. amniotic fluid embolism. Apply pressure to sites of bleeding for at least 20 mins. 3. 4. Monitor for signs and symptoms of allergic reactions. Swelling and pain in the calf of one leg are more likely to be associated with thrompophlebitis. oozing from injection sites. IUFD(Intra-uterine fetal death) or retention of dead fetus. coagulation studies show no clot formation (and are thus normal to prolonged). myocardial infarction Name of the Disease Predisposing / Contributing Factors Disseminated Intravascular coagulation Overwhelming infections particularly bacterial sepsis. assess bowel sounds and abdominal girth. major surgery. Platelet are decreased because they are consumed by the process. Institute Bleeding precautions bleeding due to 2.
increased blood urea nitrogen and creatinine. The Lippincott Manual of Nursing Practice. B. 7th ed.” hyperemesis can have serious complications. Bowel – pain. usually this is morning sickness. USA. 7th ed.. Pp. mottling. J.811) Decreased Fibrinogen level. Coronary arteries – chest pain. Lippincott company: Philadelphia. a. 1992. shortness of breath. 1992. uncontrolled vomiting that begins in . & Bare. If this is on the 1st trimester. S. Brain – decreased level of consciousness.887-888.the first weeks of pregnancy and may continue throughout pregnancy. c. 5. severe nausea and vomiting Dehydration Dry skin and mucous membranes Electrolyte imbalance Metabolic acidosis Non-elastic skin turgor 66 . Hyperemesis gravidarum Hyperemesis gravidarum is persistent.C. B. Monitor for signs of vascular occlusion and report immediately. Brunner and Suddarth’s Texbook of MedicalSurgical Nursing. f. including severe weight loss. USA. e. tenderness. CVP Heparin inhibits clotting components of DIC Anticoagulant Smeltzer.& Bare. increased fibrin split products. seizures. decreased bowel sounds.S. Eyes – Visual deficits. tachycardia. decreased antithrombin III level ECG. 2001. PTT. coma. NOTE: The defining factor for hyperemesis gravidarum should be the time of occurrence – and that is the 2nd trimester. Screening or Initial Diagnostic Test Confirmative Test Beside Equipment Best Drug Nature of the Drug References PT.. numbness. dehydration.p. usually the 14 – 16th week.blood gases. arrhythmias. Lippincott Williams & wilkins: Philadelphia.C. Bone – Pain d. Extremities – cold. Causes • • • • • • • • • Gonadotropine production Psychological factors Trophoblastic activity Assessment Findings Continuous.B.G. and electrolyte imbalance. Platelet count (Smeltzer.G. Pulmonary vasculature – chest pain. sensory and motor deficits. Unlike “morning sickness. g. b.
for example Plasil . Delivery: Actual event of birth 67 . followed by expulsion of the products of conception. Obtain blood samples and urine specimens for laboratory tests. Serum potassium level reveals hypokalemia Urine ketone levels are elevated. Labor versus Labor 1. Intrapartum care refers to the medical and nursing care given to a pregnant woman and her family during labor and delivery. Nursing Diagnoses Fluid volume deficit Altered nutrition. including Hb level. pages 483-484 IV. Labor: Coordinated sequence of involuntary uterine contractions or a result in the effacement and dilation of the cervix. Hydroxyzine and Prochlorperazine Intervention and Rationales Monitor vital signs and fluid intake and output to assess for fluid volume deficit. INTRAPARTUM CARE Intrapartum period extends from the beginning of contractions that cause cervical dilation to the first 1-4 hours after delivery of the newborn and placenta. as necessary for vomiting. From: Springhouse. Provide em0otional support to help the patient cope with her condition.• • • • • • • • • • • • • • • • • Oliguria Diagnostic Test Result Arterial blood gas and analysis reveals alkalosis. HCT. less than body requirements Pain Treatment Total parenteral nutrition (TPN) Restoration of fluid and electrolyte balance Drug Therapy Anti-emetics. 2. Teaching Topics • Using salt on foods to replace sodium lost by vomiting. Urine specific gravity is increased. Hb level and HCT are elevated. fluid replacement and TPN to reduce fluid deficit and pH imbalance. urinalysis. Maintain I.V. and electrolyte levels. Provide small frequent meals to maintain adequate nutrition.
symphysis pubis (all soften during pregnancy) 68 . coccyx.A. pelvic inlet diameters D. Sacrococcygeal. the cervix to dilate AFFECTED BY THE FOLLOWING FACTORS: A. structure of the pelvis (true versus false pelvis) C. Types of Structure Parts: ischium. factors include: A. Factors Affecting Labor FACTORS AFFECTING LABOR PASSAGEWAY • • • • Gynecoid Anthropoid Android Platypelloid PASSENGER • Fetal bones • Suture lines • Fontanels head measurements • Fetal lie • Fetal attitude • Fetal presentation • Fetal position • Fetal station POWERS PHASES • > Increment • > Acme • > Decrement ASSESSMENT • Frequency • Duration • Interval • Intensity PLACENTAL FACTORS Abruptio placenta Placenta previa Placenta acreta Placenta media PSYCHE Stress factors Leading to hypotonia I PASSAGEWAY -refers to the adequacy of the pelvis and birth canal in allowing the fetal descent. Type of pelvis B. iluim. Joints: Sacroiliac. ability of the uterine segment & vaginal canal to distend.
Structure of the Pelvis (with pelvic inlet & outlet diameters) 69 . B. d.Classifications or Types of Pelvis: a. transverse oval b. e. MOST FAVORABLE FOR SUCCESSFUL LABOR & BIRTH. Gynecoid: Normal Female Pelvis: Rounded Oval. c. Android: Normal Male Pelvis: Funnel Shape Anthropoid: oval Platypelloid: flattened.
70 . It supports the enlarge uterus in the abdominal cavity • Shallow upper basin of the pelvis • Supports the enlarging uterus but not important obstetrically LINEA TERMINALIS • Plane dividing upper or false pelvis from lower or true pelvis TRUE PELVIS Lies below the linea terminalis. MIDPLANE Pelvic cavity OUTLET Widest diameter: Anterior posterior diameter (requires the internal Relationship of fetal head for entry) Narrowest diameter: Transverse Intertuberous Diameter (facilitates delivery in Occipital Anterior Posterior) B1. Pelvic measurements a.measured from upper margin of symphysis pubis to sacral promontory.estimated on pelvic exam c. should be at least 8-9 cm. and pelvic outlet. • Bony canal through which the infant pass.Measures the outlet between the inner borders of ischial tuberosities.may be obtained by x-ray or U/S b. the bony pelvis through which the baby pass Widest diameter (transverse) Narrowest diameter (anterior – posterior) • Consists of the pelvic inlet. across the top of symphysis pubis.Distance between the inner surfaces of the symphysis pubis and sacral promontory II. Tuber-ischial diameter/ Intertuberous diameter . should be at least 11 cm. pelvic cavity. • Measurements of true pelvis influence the conduct and progress of labor and delivery. .FALSE PELVIS Above the linea terminalis. . True conjugate or conjugate vera . Obstetrical Conjugate . PASSENGER (The Fetus) Refers to the fetus and its ability to move through the passageway.
Buttocks present first b. The most common presentation b. Fetal head presents first 2 Breech a. Delivery by cesarean section 3. transverse lie at term.AFFECTED BY THE FOLLOWING FACTORS: a. the head is forward on the chest. abruptio placentae. Cephalic a. in which the fetal back is rounded.. 71 . Fetal spine is at a slight angle from a true horizontal lie b.. proven fetal distress. or the arm. Several maternal and fetal conditions make cesarean delivery necessary . 1. and cervical cerclage.the relationship of a particular reference point of the presenting part and the maternal pelvis described with a series of 3 letters or presentation refers to the part of the fetus at the cervical os Presenting part: Portion of the fetus that enters the pelvis first 1. Fetal spine is at a right angle. Fetal spine is parallel to the mother's spine b. benign and malignant tumors that block the birth canal. Oblique a. umbilical cord prolapse. especially when the lowermost twin is in a vertex presentation. major congenital anomalies. Longitudinal or vertical a. Presenting part is the shoulder c. Normal intrauterine attitude is flexion.. and the arms and legs are folded in against the body B Lie . previous cesarean birth. The relationship of the fetal body parts to one another or.. Transverse or horizontal a.. Fetal heart tones are ausculated best in the left lower abdomen when the fetus is in a left occipitoanterior position. Fetus is either cephalic or breech presentation 2. cephalopelvic disproportion. to the mother's spine b. a cesarean section may be performed NOTE: The nurse would auscultate above the umbilicus if the fetus is in breech presentation has the back above or at the umbilical area. For the heart tones to be located below the umbilicus. the fetus would be in a cephalic position. Fetal heart tones are heard best in the right lateral abdomen when the fetus is in a right occipitoposterior position. Other reasons for a cesarean delivery are more contraversial.Relationship of the spine of the fetus to the spine of the mother Transverse lie is an indication for cesarean delivery. another word is fetal posture 2. Fetus is in a transverse lie. Twins can sometimes be delivered vaginally. back.The commonly accepted indications include complete placenta previa. and severe isoimmunization. although it is often possible to deliver vaginally 3 Shoulders a.. abdomen. or side could present b. If the fetus does not spontaneously rotate or if it is not possible to turn the fetus manually. Delivery by cesarean section may be required. such as breech presentation. active genital herpes. failure to progress in labor. Delivery is by cesarean section if uncorrectable C Presentation . or perpendicular. Attitude 1.
a. oblique and occiput positions do not cause pressure on the sacrum. the soft.refers to the relationship of the fetal long axis to that of the mother's long axis. The side of the uterus where the back is located is smooth and convex to the touch. Repositioning the client and providing sacral back rubs may help alleviate the discomfort. brow b. and the opposite side has areas of indentation. complete c. round. position and attitude of the fetus. oblique (slight angle off true transverse lie). In this case. Position Relationship of assigned area of the presenting part or landmark to the maternal pelvis or the relationship of the fetus's presenting part to the mother's pelvis LEOPOLD'S MANEUVERS It is a systematic way to evaluate the presentation. The second maneuver documents the location of the fetal back. Preparation 1. SHOULDER – transverse lie NOTE: Adolescent clients maturation are usually not yet complete. CEPHALIC – vertex. firm mass indicated the fetal buttocks are in the fundus. movable object in the pubic area is the fetal head. This means that the fetal head presses against the client’s sacrum. reflecting a vertex presentation. footling. The third maneuver confirms that was what palpated in the fundus is correct and also determines whether the presenting part is engaged. which causes marked discomfort during contractions. Warm hands and apply them to the abdomen with firm and gentle pressure PROCEDURE The first maneuver determines what fetal part is in the fundal portion of the uterus. 72 . They don’t accurately determine how large the fetus is. The fourth maneuver determines id the fetal head is flexed or extended. In this case. and the engagement status of the presenting part. Ask the mother to empty the bladder 2. 5. NOTE: Lie (spine to spine) may be longitudinal (parallel). BREECH – frank.POSTERIOR POSITION. the location of the best place to auscultate the fetal heart sounds. the hard. Transverse. Fetal Position ROA: Right occiput anterior LOA: Left occiput anterior (the best fetal position) ROP: Right occiput posterior RMA: Right mentum anterior RMP: Right mentum anterior LOP: Left occiput posterior LMA: Left mentum anterior ROT: Right occiput transverse LOT: Left occiput transverse RMP: Right mentum posterior LSA: Left sacrum anterior LSP: Left sacrum posterior Severe back pain during labor maybe related to a fetus in an OCCIPITO. therefore they are very common for cephalopelvic disproportion. transverse (right angles).D. which is best determined by ultrasound. face. Fetal Lie .
Right (R) C. PART OF THE MATERNAL PELVIS A. Posterior (P) Breech PRESENTATIONS 73 . OCCIPUT (O) SACRUM (S) SCAPULA (Sc) MENTUM (M) MATERNAL REFERENCE POINT 1. B.FETAL REFERENCE POINT (PRESENTING PART) A. Transverse (T) 2. SIDE OF MATERNAL PELVIS A. Anterior (A) B. Left (L) B. C. D.
FRANK BREECH FULL / COMPLETE BREECH PRESENTATION SHOULDER BREECH FOOTLING PRESENTATION 74 .
Stages of labor 3. PLACENTAL FACTORS . CHARACTERISTICS OF CONTRACTIONS until its peak. Assessing the Fetal Heart Rate SIGNS OF IMPENDING LABOR Lightening Braxton’s-Hicks contraction Gastrointestinal upset Burst of energy Blood show #1 sign of labor Ruptured bag of water 75 . INCREMENT. 3. Nursing Interventions during labor & delivery 5. INTENSITY – the strength of contraction at its peak may be mild. LABOR 1. and strength of uterine contractions to cause complete cervical effacement and dilation. More than 90 seconds should be reported because of uterine rupture or fetal distress. duration. POWER . station of the presenting part 4. The forces acting to expel the fetus 1. and coping strategies. FREQUENCY – beginning of one contraction to beginning of one contraction. DECREMENT – diminishing intensity. B. Comparison of True Labor from False Labor 3. experiences. moderate or strong.Refers to the client’s psychological state.Refers to the site of placental insertion. V. IV. Less than 2 minutes should be reported. preparation for birth. Effacement: Shortening and thinning of the cervix during the first stage of labor 2.steep crescent slope from beginning of the contraction 2. available support systems. a. ACME/PEAK – strongest intensity. Signs of impending labor 2. Dilation: Enlargement of cervical os and cervical canal during first stage LABOR CONTRACTIONS THREE PHASES OF CONTRACTION 1.III. DURATION – beginning of one contraction until its completion. PSYCHE .Refers to the frequency.
EFFACEMENT . . especially the first few times out of bed.Descent of the fetus and uterus into pelvic cavity before labor -Occurs 2-3 weeks earlier in primipara. 4TH STAGE 1st 4 hours postpartum The precautions you should take when a postpartum client starts ambulating are the fall precaution and close monitoring should be done due to the risk of syncopy.Progressive softening “ripening” and thinning of the cervix. 3. is to watch for cord lengthening. CERVICAL CHANGES a. Rupture of amniotic membranes. The client should be encouraged to PANT BLOW or BLOW-BLOW pattern of TRUE • Regular • Become more frequent • Gradual increase in duration and intensity / progressive frequency & intensity • Begins at lower back and radiates around abdomen • • • • • Contractions are intensified Progressive dilation and effacement Present Pain doesn’t disappear Contractions doesn’t stop FALSE • Irregular • Unchanged • Unchanged or decrease in frequency and intensity • • • • • • Primarily on the lower abdomen & groin Lessened or not affected No change Not present Pain disappears Contractions stops STAGES OF LABOR 2ND STAGE Full cervical dilatation to delivery 3RD STAGE Delivery to placental expulsion The nurse should know if the placenta is going to be delivered. NESTLING BEHAVIORS 6. PREMONITORY SIGNS OF LABOR 1. Regular Braxton Hicks’ contractions. DILATION . a slight gush of darkened blood or a change in fundal shape.In multipara.1. LIGHTENING . may not occur until labor begins. . Weight loss of about 1-3 lbs 2-3 days before labor onset.“BLOODY SHOW” (expulsion of mucous plug) b. 2. 76 . COMPARISON OF TRUE AND FALSE LABOR CHARACTERISTICS Contractions onset. Discomfort Effects of walking Cervical changes Show During sleep During Sedation 3. 1ST STAGE Contraction to dilation Preparatory division: 1) Latent phase 0-3 cm Duration: 30 – 45 seconds NOTE: Pushing during the first stage of labor when the urge is felt but the cervix is not yet fully dilated may produce cervical swelling and makes labor more difficult. 5.Opening of cervical os during labor. 2. 4.
May lose control. 77 . Circumoral pallor NOTE: If the client is in active labor and there is no change in dilation after 2 hours.breathing to help overcome the urge to push. To assess the suture most readily felt. Pressure on bladder and rectum. the nurse performs a vaginal examination. prolonged transitional phase (pushing). the nurse would determine the position of the cranial suture termed-SAGITALL SUTURE. nauseous and vomiting common.100% DILATION . Increased show.60-90 seconds MANIFESTATIONS: Client may be irritable and panicky.8-10 cm CONTRACTIONS FREQUENCY . Trembling of legs. Backache. and contraction pattern. the nurse should suspect cephalopelvic disproportion. The client is not experiencing a prolonged latent phase (0-3 cm). Amnesic between contractions. NOTE:Vaginal Examination To determine if the client is fully dilated. 2) Active phase 4-7 cm Duration: 45-60 seconds 3) Transitional phase 8-10 cm Duration : 60-90 seconds FIRST STAGE OF LABOR (ONSET OF REGULAR CONTRACTIONS TO FULL CERVICAL DILATION TRANSITION PHASE TIME: PRIMIPARA (1hour) MULTIPARA (10 – 15 minutes) CERVIX: EFFACEMENT . Perspiring.2-3 minutes DURATION .
If the perineum is bulging.60-90 seconds INTENSITY VERY HARD: 100 mm Hg MANIFESTATIONS: Decrease in pain from transitional level. increased bloody show. the #1 nursing intervention is to look for perineal bulging (crowning). THIRD STAGE OF LABOR (DELIVERY OF NEWBORN TO DELIVERY OF PLACENTA) TIME: 5-30 minutes CONTRACTIONS • 78 . . -1 DIPPING) • • • Station 0: at ischial spine 0 means ENGAGEMENT Plus station: below ischial spine + 1 TO + 5 indicates a presenting part below zero station +3 CROWNING “My baby is coming”.STATION Refer to the level of presenting part of fetus in relation to imaginary line between ischial spines (zero station) in mid pelvis of mother.2-3 minutes DURATION . Excited eager and in control.The measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine • Minus station: above ischial spine -5 to –1 indicates a presenting part above zero station (-3FLOATING. the patient should be coached to pant with her contractions so that she doesn’t push. Fetal heart rate is focus on the labor process or potential fetal cord compression and meconium stained complications SECOND STAGE OF LABOR (COMPLETE CERVICAL DILATION TO BIRTH OF NEWBORN) TIME PRIMIPARA (30-50 minutes ) MULTIPARA (20 minutes) CONTRACTIONS FREQUENCY .
• Prepare for delivery.Place identification band on baby and mother. . . monitor FHR. • Administer analgesics as indicated. . intensity. • Immediate newborn care at delivery.Establish airway.Administer prophylactic eye drops and vitamin K. MANIFESTATIONS: Lochia rubra Exploration of newborn Parent-infant bonding begins Newborn alert and responsive First period of reactivity NURSING INTERVENTIONS DURING LABOR AND DELIVERY • During labor. perineal bulging. This stage lasts from 1-4 hours after birth. and patterns of uterine contractions • Monitor fetal status during labor by monitoring fetal heart rate • Assess bloody show (pink or blood streaked mucus).Assess the newborn’s gestational age. UTERUS The uterus contracts in the midline of the abdomen with the fundus midway between the umbilicus and symphysis pubis.Clamp umbilical cord. . . NURSING CARE DURING LABOR STAGE 1 PHASE Latent ASSESSMENT Onset of labor until cervical dilatation of 4 cm. . .Strong and well-contracted uterus changing to globular shape MANIFESTATIONS: Increased gush of blood Uterus becoming globular with fundus rising in the abdomen Apparent lengthening of cord FOURTH STAGE OF LABOR (DELIVERY OF PLACENTA TO HOMEOSTASIS) TIME Usually defined as the first hour postpartum. NURSING CONSIDERATION • Monitor frequency.Maintain warmth. membrane status • Periodic vaginal exams • Monitor vital signs • Assess client’s ability to cope with 79 .Observe Apgar score at 1 and 5 minutes interval. • Provide patient comfort.
contributing to hemorrhage • Promote parent-infant bonding 4 The period of immediate recovery and 80 . the fundus may be deviated to the right or left. helping position her legs for maximum pushing effectiveness. Constant massaging would tire the uterine muscle. • The fundus should descend approximately 1-2 cm every 24 hours • NOTE: The fundus should not be massaged unless it is relaxed. 1 vein) • Assess placenta for intactness • The fundus should be midline at or two cm. The fundus should be palpated in the midline of the abdomen. 3 From delivery of the fetus to delivery of the placenta. The fundus should be at the level of the umbilicus on the day of delivery and falls below the umbilicus by approximately one fingerbreadth (1 cm) per day. until it has contracted into the pelvis by the 9th or 10th day. the fundus should be firm and two fingerbreadths below the umbilicus. The fundus should be firm. if the woman has a full bladder. however.• contractions Provide emotional support 2 From dilation to delivery of the fetus Prep client for delivery Immediate assessment of the newborn Nursing care for the client during the second stage of labor should include assisting the mother with pushing. not soft. usual within 5-20 mins. Of delivery • Assess umbilical cord for 3 vessels (2 arteries. A soft or boggy fundus indicates that the uterus isn't contracting properly. and monitoring the fetal heart rate • • . Below the umbilicus By the 2nd postpartum day.
and place the ultrasound transducer over this area (fasten with a belt) 3. and intensity of contractions. The external monitor doesn’t accurately record intensity of the contractions. the fundal height descends into the pelvis one finger’s-breadth per day. ASSESSING THE FETAL HEART RATE V. and it doesn’t accurately record fetal heart rate variability. assesses FHR in relation to maternal contractions. C. Description 2. NOTE: The patient with the fetus in a vertex position and meconium-stained fluid would have the highest priority of being monitored with internal fetal monitoring.observation after delivery of the placenta. Approximately 2 hours • Assess maternal vital signs. Internal fetal monitoring requires that the patient have ruptured 81 . External fetal monitoring 1. assesses frequency. Generally. Monitors uterine activity. duration. the normal FHR is 120 to 160 beats per minute B. Allow the client to assume a comfortable position. • Assist indicated breastfeeding efforts if In teaching the client about postpartum weight loss in relation to breastfeeding the factors that should be considered is the caloric needs of a nursing mother and dieting should be avoided. fundal height. Invasive and requires rupturing of the membranes and attaching an electrode to the presenting part of the fetus. The patient with the meconium-stained amniotic fluid is at high risk for fetal distress. in order to maintain adequate milk supply. Internal fetal monitoring 1. avoiding vena cava compression NOTE: The external fetal monitor records the contractile pattern and the fetal heart rate response to the contractions. FETAL MONITORING A. Noninvasive and performed by the use of a tocotransducer or Doppler ultrasonic transducer 2. lochia and bladder distention One hour after birth expect the fundal height at midway between the umbilicus and the symphysis pubis. It is the baseline FHR measured between contractions. Place the tocotransducer over the fundus of the uterus where contractions feel the strongest (fasten with a belt) 4. Perform Leopold's maneuvers to determine on which side the fetal back is located.
Maternal or fetal infection Fetal hypoxia (an ominous sign) • Fetal hypoxia or stress • Maternal hypotension after epidural initiation INTERVENTION • • • Dependent upon cause Early deceleration (Deceleration begins and ends with uterine contraction) Late deceleration (HR decreases after peak of contraction and recovers after contraction ends) Head compression (not ominous) Vaginal stimulation • • • • • Fetal stress and hypoxia Deficient placental perfusion Supine position Maternal hypotension Uterine hyperstimulation Place client on left side Increase fluids (to counteract hypotension) • Stop oxytocin (Pitocin) if in use Not required • Change maternal position • Correct hypotension • Increase I. and vacuum extraction..p. Sterile vaginal examinations are necessary to monitor the patient’s progress during labor and. and evaluating the fetal response to the 82 .m. shouldn’t pose additional risk of HIV transmission to the fetus FETAL HEART RATE PATTERN Tachycardia (>160 b.) INDICATIVE OF…. shouldn’t be done unless absolutely indicated. Each of those procedures either causes or has the potential to use a break in the fetal skin. fluid rate as ordered • Discontinue oxytocin (Pitocin) NOTE: Nursing interventions for uteroplacental insufficiency include repositioning to side-lying position. if performed appropriately. In many institutions. if it’s being infused. assessing maternal vital signs for evidence of hypotension. and when the cervix is dilated at least 2 cm.V. Fetal monitoring is most useful in situations in which a high probability exists of maternal contractile problems or fetal distress. Mother must be dilated 2 to 3 cm to perform internal monitoring NOTE: To prevent exposure to human immunodeficiency virus (HIV).membranes and be dilated at least 1 cm and that the fetal presenting part is reachable.) Bradycardia (<120 b. Non-stress test and ultrasonography aren’t noninvasive procedures and don’t increase the risk of transmission of HIV to the fetus. administering oxygen by tight face mask at 10 to 12 L/minute.p. fetal monitoring is used routinely on all patients. NOTE: Internal EFM can be applied only after the client's membranes have ruptured. increasing I. when the fetus is at least at the –1 station. Although the client may receive anesthesia. it isn't required before application of an internal EFM device. thereby increasing the risk of transmission of HIV to the fetus. invasive procedures.m. 2. such as fetal scalp sampling. Fetal monitoring provides an almost continuous recording of labor events. fluids. discontinuing the oxytocin.V.
but the priority is to change the woman's position and relieve cord compression. A continuous process from the time of engagement until birth. and is assessed by the measurement called station Descent Also termed lightening or dropping Descent The process that the fetal head undergoes as begins its journey through the pelvis 83 . such as changing position and amnioinfusion with sterile saline. Change maternal position (left lateral position) Administer O2 Decreased baseline) variability (smooth Dependent upon cause Mechanisms of Labor Engagement or Cardinal movements by the Fetus Definition: Mechanism by which the fetus nestles into the pelvis. Hypoxia or hypercarpnia Fetal sleep cycle Depressant drugs Hypoxia CNS anomalies • Administer oxygen as ordered .interventions. indicating compression of the umbilical cord. The first action when uterine cord occurs is to relieve pressure on the cord by changing the patient’s position. If the cord is pulled on before the placenta has separated there will be a uterine inversion or retained placental fragments. Once you have checked the cord. An emergency cesarean section is necessary only if other measures. Changing the client's position from supine to side-lying may immediately correct the problem. prove unsuccessful. the rest of the body should be delivered with an application of gentle traction on the anterior shoulder. Variable deceleration (Transient decrease in anytime during contraction) HR Cord compression Variable decelerations in fetal heart rate are an ominous sign. Administering oxygen may be helpful. advising the patient not to push.
face. assumed at engagement into the pelvis. Internal Rotation Internal rotation of the fetus. and chin pass over the sacrum and coccyx are over the perineum Restitution Realignment of the fetal head with the body after that head emerges External Rotation The shoulders externally rotate after the head emerges and restitution occurs. brow.Flexion Process of the fetal head's nodding forward toward the fetal chest Suboccipotobregmatic: the diameter that presents to the maternal pelvis during COMPLETE FLEXION. to the occipital anterior position while continuously descending Extension Enables the head to emerge when the fetus is in a cephalic position Begins after the head crowns Is complete when the head passes under the pubis and occipital. so that the shoulders are anteroposterior diameter of the pelvis Expulsion The delivery baby CARDINAL MOVEMENTS OF THE FETUS Descent Expulsion Flexion Internal Rotation Extension External Rotation 84 . most commonly from the occipital transverse position. and the anterior fontanel.
A spinal block is given during the active phase of the first stage of labor. A spinal block is given during the active phase of the first stage of labor. Narcotic analgesics and pericervical block are administered during the active phase of labor. if administered. Sedative hypnotics. are given when the patient is in early latent labor to encourage rest. pudendal block. Administered just before the birth of baby 3. Provides a rapid block of uterine pain 3. Local anesthesia 1. Paracervical block 1. No effect on the fetus B. No effect on the perineal area 4. Used for blocking pain during episiotomy 2. NOTE: NOTE: NOTE: The chief concepts of Lamaze teaching include conditioned responses to stimuli through use of a focal point. May cause fetal bradycardia 85 . An emotionally satisfying experience is promoted rather than discouraging use of analgesia and anesthesia. No effect on the ability to bear down 5.DESCENT FLEXION INTERNAL ROTATION EXTENSION EXTERNAL ROTATION EXPULSION Figure 18 Cardinal Movements or Mechanism of labor VII. A. ANESTHESIA Analgesia administered during the second stage of labor includes continuation of the lumbar epidural block. Used in the first stage of labor 2. and local infiltration of the perineum.
Effect lasts about 30 minutes 5. Injection site at pudendal nerve through a transvaginal route 3. A patient who is about to receive epidural anesthesia should empty her bladder before the procedure because an epidural will lessen the sensation to void so voiding now may decrease the need for catheterization later. Assess maternal blood pressure 7. Administered after labor is established or just before a scheduled cesarean birth 3. After epidural anesthesia the vital signs should be monitored every 1-2 minutes for the first 15 minutes. Administered just before the birth of the baby 2. E. Injection site in spinal subarachnoid space at L3-L5 2. Pudendal block is adequate for episiotomy and its repair. The major complication of epidural anesthesia is maternal hypotension.V. increase variability and meconium stained are NOT associated. To prevent hypotension. D. the patient receives a bolus of 500 to 1. It does not relieve pain primarily in the perineum and vagina. and lower extremities 86 . Administer IV fluids as prescribed 9. NOTE: To minimize the hypertensive effects of epidural anesthesia prior to the procedure adequately hydrate the patient and position the patient side lying to the left.C. Relieves uterine and perineal pain and numbs vagina. Increase fluids as prescribed if hypotension occurs 9. which would cause impaired gas exchange in the fetus. The patient isn’t affected by these problems because she didn’t receive the epidural anesthesia. The fetus should be assessed for BRADYCARDIA which is a potential complication of pudendal block anesthesia. No effect on contractions or fetus NOTE: Pudendal Block Anesthesia The #1 purpose is to relieve pain primarily in the perineum and vagina. NOTE: A common adverse effect of epidural anesthesia is hypotension. May cause hypotension 5. Injection site in epidural space at L3-L4 2. The assessment should be a high priority after a patient has received an epidural is blood pressure because an epidural can cause hypotension and its blocks the autonomic nervous system. perineum. Blocks perineal area for episiotomy 4.000 ml of I. fluid before the procedure. NOTE: The patient plans to receive an epidural anesthetic for pain relief during labor. reduced responsiveness and seizures. Maintain the mother in side-lying position or place a rolled blanket beneath the right hip to displace the uterus from the vena cava 8. it won’t be administered until the patient is dilated 4 to 5 cm. Does not cause headache because the dura mater is not penetrated 6. Relieves pain from contractions and numbs vagina and perineum 4. Epidural block 1. Spinal block 1. Decrease movements. Maternal Adverse effects are the following: hypotonia. Administered just before birth 3. Pudendal block 1.
Oligohydramnios is associated with intrauterine growth retardation (IUGR) and congenital disorders D . or if fetal distress is note NOTE: Oxytocin (Induction of Labor) Before the induction of Labor. the client is not a candidate or if contractions occur less than 2 minutes apart or last longer than 60 seconds C.External version 87 . Discontinue oxytocin as prescribed contraction frequency is less than 2 minutes or duration more than 90 seconds. Performed if the fetus is at "0" or "+" station 3. The mother is not awake 3. Elective induction may be accomplished I oxytocin (Pitocin) infusion 3. General anesthesia 1. Oxytocin Induction 1.4. May be used for some surgical interventions 2. Do not increase rate of oxytocin once the desired contraction pattern is obtained (contraction frequency of 2 to 3 minutes and lasting 60 seconds) 6. Place a rolled blanket under the right hip to displace the uterus from the vena cava 8. The mother must lie flat 8 to 12 hours following spinal injection 7. May cause maternal hypotension 5. Obtain baseline tracing of uterine contractions and FHR 4. the nurse should obtain a baseline measurement of the fetal heart rate. If the fetal heart rate pattern shows fetal distress. and characteristic of fluid 6. Increase IV dosage of oxytocin as prescribed only after assessing contractions. Record time of AROM. Polyhydramnios is associated with maternal diabetes and certain congenital disorders 10. An unpleasant odor to amniotic fluid is associated with infection 9. Monitor FHR before and after AROM 5. and maternal blood pressure and pulse 5. Amniotomy 1. Presents a danger of respiratory depression vomiting OBSTETRICAL PROCEDURES A. performe by the physician to stimulate labor 2. Administer IV fluids as prescribed F. Artificial rupture of membranes (AROM). Increases risk of prolapsed cord and infectic 4. FHR. May cause postpartum headache 6. Meconium-stained amniotic fluid may be associated with fetal distress 7. A deliberate initiation of uterine contractions this stimulates labor 2. Bloody amniotic fluid may indicate abrupt placentae or fetal trauma 8. FHR.
Abdominal wall is manipulated to direct fetus into a cephalic presentation if possible 9. spoon like articulated blades that are used to assist. perform Kleihauer Betke test as prescribed to detect the presence and amount of fetal blood in the maternal circulation and to identify clients who need additional Rh immune globulin i. ensure quick delivery of the placenta or cause enlarging the pelvic inlet. Instruct the client in the use of sitz baths 6. substitutes a clean surgical incision for a tear and decreases undue stretching of perineal muscles. An episiotomy does not prevent perineal edema. 1. If the mother is Rh-negative. it prevents tearing of the perineum. An episiotomy helps prevent tearing of the rectum but does not necessarily relieve pressure on the rectum. and decreased fetal activity c. Provide ice pack during the first 24 hours 5. in the delivery of the fetal head 2. External manipulation of the fetus from an abnormal position into a normal presentation 2. ruptured membranes. Indicated for an abnormal presentation that exists after the 34th week 3. bleeding. The advantage of an episiotomy is that it facilitates the delivery of the fetus. . Provide perineal care. Apply analgesic spray or ointment as prescribed 7. Prepare for nonstress test to evaluate fetal well-being 6. Following the procedure a. Apply a peripad without touching the inside surface of the pad 12. F. Episiotomy = The purpose of episiotomy is to shorten the 2nd stage of labor. Forceps delivery 1.Monitor for uterine activity. With Rh-negative clients. Monitor mother and fetus during delivery possible injury 5. Institute measures to relieve pain 4. Instruct the client to dry the perineal area from front to back and to blot the area rather than wipe it 10. ensure that RH immune globulin was given at 28 weeks gestation 5. Incision made into perineum to enlarge vaginal outlet and facilitate delivery 2. and it prevents undo stretching of the perineal muscles. Report any bleeding or discharge to the physician 13. Instruct the client to shower rather than bathe in a tub 11. Two double-crossed. Monitor vital signs 4. Perform nonstress test to evaluate fetal well-being b. Monitor blood pressure to identify vena cava compression 10. Ultrasound is used during the procedure to evaluate fetal position and placental placement and guide direction to the fetus 8.1. using clean technique 8. IV fluids and tocolytic therapy may be administered to relax the uterus and permit easier manipulation of fetus 7. Instruct the client in the proper care of the incision 9. Assist with repair of any lacerations 88 . Check episiotomy site 3. Reassure the mother and explain the need for forceps 3. Monitor for unusual pain 11.
Monitor for signs of infection and bleeding f. and deep breathing d. A tender uterus and foul-smelling lochia may indicate endometritis h.G. Prepare the abdomen as prescribed g. Caput succedaneum is normal and will resolve in 24 hours H. Provide emotional support i. Preoperative a. Provide pain relief c. ETIOLOGY PROM Incompetent cervix Multiple gestation SIGNS /SYMPTOMS Low back pain Suprapubic pressure Vaginal pressure ASSESSMENT Obtain thorough obstetric history Obtain specimen for CBC & U/A Determine frequency. Vacuum extraction 1. Suction is used to assist in delivery of the fetal head 3. quickly explain the need and procedure to the mother and partner c. If an emergency. The suction device should not be kept in place any longer than 25 minutes 5. prepare the mother and partner b. Cesarean delivery 1. Burning and pain on urination may indicate a bladder infection g. A cap like suction device is applied to the fetal head to facilitate extraction 2. If planned. Postoperative a. Monitor FHR every 5 minutes if external fetal monitoring is not used 6. low-segment incision of the uterus 2. Administer preoperative medications as prescribed 3. Delivery of the fetus usually through a trans-abdominal. Assess newborn infant at birth and throughout postpartum period for signs of cerebral trauma 7. coughing. Monitor vital signs b. Encourage ambulation e. Prepare to insert an IV line and a Foley catheter f. Monitor the mother and fetus continuously for signs of labor h. duration & 89 . Monitor for developing cephalohematoma 8. including the Rh factor e. Make sure that the preoperative diagnostic tests are done. A productive cough or chills may indicate pneumonia COMPLICATIONS OF LABOR AND DELIVERY Preterm Labor Preterm labor is labor that begins after 20 weeks gestation and before 37 weeks gestation. Traction is applied during uterine contractions until descent of the fetal head is achieved 4. Encourage turning. Obtain informed consent d.
with ritodrine. RDS (before 38 weeks MANAGEMENT MANAGEMENT: With infection: antibiotics and delivery of infant Without infection: 34-36 weeks of gestation= delay birth. Provide adequate hydration Provide emotional support . Leakage of amniotic fluid 2. not hyperkalemia.Spontaneous rupture of amniotic membranes prior to onset of labor.p. amniocentesis and monitor LS ratio of the baby 28-32 weeks of gestation= delay birth. administer steroids to hasten maturity of the lungs and decreased RDS The good indicator of fetal lung maturity in a pregnant diabetic is presence of phosphatidglycerol in the amniotic fluid.5 3. Ritodrine may cause tachycardia. not fall. Prolapsed cord 2. tocolytic and steroid therapy • Administer meds as prescribed • Assess S/E such as hypotension. not bradycardia. so it must be assessed whether the feelings are from the medication or from the Preterm labor Steroid therapy PROM (Premature Rupture of Membrane) NURSING MANAGEMENT Perform measures to manage or stop Preterm labor • Place on CBR in side-lying position • Prepare fro possible ultrasound. Ritodrine may also cause hypokalemia. chest pain and FHR exceeding 180 b. size and maturity MANAGEMENT Goal: PREVENTION OF PRETERM DELIVERY Conservative Treatment: Bed rest in lateral position Hydration w/ IVF and continuous fetal and uterine contraction monitoring Tocolytic Therapy: Beta mimetic agents: Ritodrine (Yutopar) Use of ritodrine can lead to pulmonary edema. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy. Infection 3. Umbilical cord prolapse 90 .m.Previous history of Preterm labor DES exposure Emotional stress Hydramnios Placenta previa Abruptio placenta Maternal age <18 or >35 Rhythmic uterine contractions (2 uterine contractions lasting 30 seconds within 15 minutes) Cervical dilatation <4 cm & effacement 50% or less Expulsion of cervical mucus plus Bloody dhow intensity of uterine contractions Determine cervical dilatations and effacement Assess status of membranes and bloody show Evaluate fetus for distress. amniocentesis. maybe preterm gestation) or term ASSESSMENT CONTRIBUTING FACTOR Incompetent cervix Trauma Infection SIGNS AND SYMPTOMS 1. Nitrazine paper reaction = blue RISK FOR: 1. A. Blood glucose levels may temporarily rise. Therefore. pH higher than 6. dyspnea. the nurse should assess for crackles and dyspnea. Ritodrine (Yutopar) can cause tremor and jittery feelings.
PROLAPSE UMBILICAL CORD Figure 23 Definition Synonyms Predisposing Factors PROLAPSE UMBILICAL CORD The umbilical cord is displaced. Twin gestation. Unengaged presenting part. Polyhydramnios Multiple fetal gestation FetoPelvic disproportion Abnormally long umbilical cord. moist skin Dystocia Rupture of Membrane spontaneously The cord may then present/visible @ the vulva. either between the presenting post and the amnion or protruding through the cervix. Placenta Previa Intrauterine tumors that prevent the presenting part from engaging > Breech presentation. Note: Do not attempt to push the cord into the uterus. You can determine if a prolapsed cord exists if you perform a vaginal exam.If the fetus is at –2 station and the membranes rupture. the patient is at risk for prolapsed cord. Amniotomy: Rupture of Membranes Initial Sign Late Sign Cardinal Sign Confirmatory Test 91 . Transverse lie. Cord Prolapse Fetal Position other than cephalic presentations Prematurity: NOTE: Small fetus allows more space around presenting part. Hydramnios Small fetus Cord Prolapse: NOTE: first discovered when there is variable decelerated pattern FHR pattern variable: Decelerations with contractions or between contraction or fetal bradycardia present Persistent non reassuring fetal heart rate – fetal distress Atrophy of the umbilical cord & cord protruding from vagina Cord may be palpated in cervix/vagina Reflex constriction when cord is exposed to air Cool.
The primary goal with a prolapsed of the umbilical cord is to remove the pressure from the cord. which can lead to central nervous system damage in the fetus. p.300) (Pillitteri.chest position Oxygen Push presenting part upward Apply moistened sterile towels Delivery as soon as possible Nursing Intervention (Pillitteri.Causing compression of the cord and compromising fetal circulation OTHERS: Prematurity. Instruct patient to cleanse from the front to the back. Fast vaginal delivery with forceps #1 Maternal & Fetal Infection . Administering the oxygen benefits the fetus only if circulation through the cord has been reestablished. Turn side to side -Helps may be elevated to shift to fetal presenting toward diaphragm. Changing the maternal position is the first intervention.578-579) 92 . side-lying and elevation of the hips. Explain the importance of hand washing before and after perineal care. Bedside equipment Best Drug Nature of the drug History of the Disease Nursing Diagnosis Eternal Electronic Fetal Heart Rate monitoring Oxygen with face-mask. If the fetus doesn’t receive adequate oxygen. Maternal and Child Nursing. Sterile hand glove Heparin IV To control intravascular coagulation in the pulmonary circulation Fetal nutrients supply Compression of the umbilical cord Fluid volume deficit related to active hemorrhage Altered tissue perfusion related to maternal vital organ and fetal related to hypovolemia Risk for infection related traumatize tissue NOTE: The nurse’s #1 priority action to a prolapse cord is to assess the fetal heart rate. Acceptable positions include knee-chest. Meconium aspiration. Use of large-gauge catheter when starting the IV for blood and large quantities of fluid intake. A prolapsed cord interrupts the oxygen and nutrient flow to the fetus. Start or maintain an IV as prescribed. hypoxia develops. Maternal and Child Nursing. Administer oxygen by face –mask to provide high oxygen concentration at 8 –10L/min. Hypoxia.Best Major Surgery Disease Complication Cesarian Section if the cervix incompletely dilated.Fetal death if delayed or undiagnosed Best Position Trendelenberg’s position or Knee Chest position -which causes the presenting part to fall back from the cord. The nurse may also perform a vaginal examination and attempt to push the presenting part off the cord. OTHER MANAGEMENT: Reposition client to trendelenburg or knee. p.
Fear. Stress increase fatigue Management: i. abnormal progress of labor of more than 24 hours 1. painful. Passageway Contracted pelvis Unfavorable pelvic shapes Management: i. Monitor clients psychologic response to labor ii. Perform assisted vaginal or caesarean delivery 3. Infection The infant is at risk to develop thrush if the pregnant woman has monillial infection at the time of vaginal delivery Infection 93 . anxiety ad tension increase stress and decrease uterine contractility b.F. Dystocia . a. Powers/ uterine inertia/ contraction HYPERTONIC LABOR PATTERNS (Primary inertia) Latent phase of labor Rest and sedation Fetal monitoring HYPOTONIC LABOR PATTERNS (Secondary inertia) Active phase of labor Oxytocin and amnionity Cesarean section if labor does not resume Early analgesia Bowel or bladder distention Multiple gestation Large fetus Hydramnios Grandmultiparity OCCURRENCE TREATMENT CAUSES 2.Difficult. Evaluate pelvic diameters ii. Determines clients level of stress iii. Psyche a. Continue labor with careful monitoring iii. b. Stress interferes with the clients ability with her contractions c. Provide support iv. Encouraged relaxation D.
and (in the neonate) the walls of the gastrointestinal tract -Prenatal transmission from infected mother to fetus or newborn via transplacental transmission. uterine rupture. or through breast milk b. Precipitate delivery . vaginal mucosa. and excessive uterine bleeding. While transmission rates of HIV infection from mother to infant range from 30% to 75%. Nursing Management Avoid procedures that increase the risk of prenatal transmission. professionals estimate the actual transmission rate at about 40% to 50%. In options 3. Across the placental barrier B. Therefore. transmission from mother to fetus\child can occur transplacentally throughout pregnancy. such as amniocentesis and fetal scalp sampling Note that if the fetus has not been exposed to HIV in utero. the highest risk exists during delivery through the birth canal Never use scalp electrodes Avoid episiotomy to decrease the amount of maternal blood in and around the birth canal Promptly remove the neonate from the mother's blood following delivery • NOTE: HIV has been found to be transmitted through the breast milk from mother to baby.Labor that is completed within 3 hours A pregnant patient with a known history of crack cocaine use is in labor must be prepared for a precipitous labor and notify the neonatologist of the infant’s high-risk status. The AIDS virus is passed transplacentally. the result of the labor process would be laceration of the soft tissues. breast feeding isn’t recommended for a mother who is HIV-positive. so cesarean delivery will not prevent infection of the neonate.Clamydia Gonorrhea Syphilis AIDS TORCH ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) a. In the option 4. If a patient has a precipitous labor at risk. trough contact with the mother’s blood and vaginal secretions at delivery and through ingestion of break milk. a newborn can be symptom-free at birth and still develop AIDS. Via breast milk -HIV can cross some membranes such as the placental barrier. via contamination with maternal blood during birth. A true diagnostic of HIV infection in neonates cannot actually be made until around 15 months of age. G. Transmission A. During the process of labor and delivery C. ASSESSMENT NURSING INTERVENTION 94 . the blood-brain barrier.
Uterine Rupture The two findings on physical exam indicate uterine rupture is loss of uterine contour and palpable fetal part. FHT ceased Signs of shock I. or hyperstimulation of the uterus. Possibly administer tocolytic agents 3. but cervix fail to dilate Vaginal bleeding may be present Rising pulse rate and skin pallor Loss of fetal heart tones An amniotic fluid embolism is when the amniotic fluid leaks into the maternal bloodstream bThe causes of an amniotic fluid embolism are difficulty in labor. Perineal lacerations & Hemorrhage When delivering the neonate. COMPLETE Sudden sharp abdominal pain during contractions Abdominal tenderness Cessation of contractions Bleeding into abdominal cavity & sometimes into vagina Fetus easily palpated. you should deliver the head between contractions. Premature or small fetus 4.Predisposing Factors: 1. Amniotic fluid embolism INCOMPLETE Abdominal pain during contractions Contractions continue. Multiparity 2. thuds preventing a possible tearing of the perineum. • • • • MANIFESTATION Dyspnea Sharp. Prepare for emergency birth 1. blood-tinged mucus MANAGEMENT • • • • Oxygen CPR Intubation Delivery 95 . Fetal Cerebral trauma H. History of rapid labor 3. The number one risk factor for uterine rupture is previous cesarean section. This will prevent the head from being delivered too suddenly. 3. Polyhydramnios is an excessive amniotic fluid. chest pain Pallor or cyanosis Frothy. Large bony pelvis Risks: Management: 1. Monitor client and fetus closely 2.
LOCHIAL CHANGES LOCHIA RUBRA • Dark red discharge occurring in the first 2-3 days. • Serosanguineous discharge containing decidua. • Contains leukocytes. LOCHIA ALBA • Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery. POSTPARTUM PHYSIOLOGICAL MATERNAL CHANGES A. UTERUS • • • . by 10-14 days postpartum. • Characteristic human odor. cholesterol crystals. decidua. cervical mucus and microorganisms. LOCHIA SEROSA • Pinkish to brownish discharge occurring 3-10 days after delivery. Fundus steadily descends into true pelvis.epithelial cells. cervical mucus. 96 . Increasing Lochia as the day passes by may indicate Heparin Intoxication. erythrocytes. leukocytes. B.SECTION V. • Has no odor. Weight decreases from 2 lbs to 2 oz. cannot be palpated abdominally. and bacteria. • Contains epithelial cells. erythrocytes and decidua. LOCHIA – discharge from the uterus during the first 3 weeks after delivery. Process of involution takes 4-6 weeks to complete. fat. • Has a strong odor. Fundal height decreases about 1 fingerbreadth (1 cm)/day.
Uterine Involution 1. Assessment a. Hemorrhoids are common 97 . Endometrium regenerates c. By 10 days postpartum. 3. The rapid decrease in the size of the uterus as it returns to the nonpregnant state b. Women are usually very hungry after delivery 2. Breasts 1. Breasts become distended with milk on the third day 4. Engorgement occurs in 48 to 72 hours in non breast feeding mothers.C. A decrease in estrogen and progesterone levels after delivery stimulates increased prolactin levels. which promote breast milk production. Weight of the uterus decreases from 2 pounds to 2 ounces in 6 week b. Breasts continue to secrete colostrum 2. Description a. The top of the umbilicus is normally MIDWAY between the umbilicus and the symphysis pubis. Fundal height decreases about 1 fingerbreadth (1 cm) per day E. Constipation can occur 3. Gastrointestinal tract 1. NOTE: Bradycardia is a normal physiologic change for 6-10 days postpartum E. Fundus steadily descends into the pelvis d. Clients who breastfeed may experience a more rapid involution 2. uterus cannot be palpated abdominally NOTE: Deviation of the fundus to the right or left and location of the fundus above the umbilical are signs that the bladder is distended NOTE: Height of the Umbilicus on the First Postpartum Day The height is usually SLIGHTLY below the umbilicus about 24 hours after delivery. D.
and location of the fundus breastfeeding does not give adequate protection. Check episiotomy and perineum for signs of infection. and location of the fundus Monitor color. Rhogam (D) immune globulin is given by intramuscular injection. and then inhale deeply while allowing the abdomen to expand and exhale while contracting the abdominal muscles.success depends on infant sucking and maternal production of milk. • • • • 98 . Examples are reaching for the knees. Nursing woman. push ups and sits ups on the first postpartum day. consistency. minimizes breast stimulation. Remind that Assess height. The nurse can reassure the new mother that these symptoms are normal. The mother also increase the time spent in the en face position. The mother follows a progression of touching activities from fingertip exploration toward palmar contact to enfolding the infant with the whole hand and arm. The purpose of this exercise is to strengthen the abdominal muscles. consistency. Postpartum Exercise Supine Position with the knee’s flexed. and odor of lochia Assess lochia and color volume Give RhoGAM to mother if ordered. amount. Promote successful feeding. ice packs. Assess height. Administer RhoGam as prescribed within 72 hours postpartum to the Rh-negative client who has given birth to an Rh-positive neonate. POSTPARTUM NURSING INTERVENTIONS Monitor vital signs • • NOTE: Maternal temperature during the first 24 hours following delivery may rise to 100. The mother arranges herself or the newborn so that her face and eyes are in the same plane as in her infant.III. Observation of new mothers has shown that a fairly regular pattern of maternal behaviors is exhibited at first contact with the newborn. 4` F (38`C) as a result of dehydration. RhoGAM promotes lysis of fetal Rh (+) RBCs. “Postpartum Blues” (3-7 days) – Normal occurrence of “roller coaster” emotions Sexual activities. Non-nursing woman.abstain from intercourse until episiotomy is healed and lochia ceased around 3-4 weeks.tight bra for 72 hours. Assess breasts for engorgement Monitor episiotomy for healing ( assess dehiscence & evisceration) Assess incisions or dressings of cesarean birth client ( prone to infection) Monitor bowel status ( prone to constipation) Monitor I &0 Encourage frequent voiding (prevent urinary retention which will predispose the mother to uterus displacement & infection) Encourage ambulation ( to prevent thromboplebitis & paralytic ileus) Assess bonding with the newborn infant ( to prevent failure to thrive) NOTE: A positive bonding experience is indicated when the mother turns her face toward the baby to initiate eye-to-eye contact.
IV. Apply ice packs between feedings NOTE: Specific Nursing Care for Cracked nipples 1. NOTE: Specific nursing care for breast Engorgement 1. APPLYING ICE and LANOLIN DOES NOT RELIEVE BREAST ENGORGEMENT. Breastfeed frequently 2. Expose nipples to air for 10 to 20 minutes after feeding 2. so that a ravenous neonate is not sucking vigorously at the beginning of the feedings. Apply warm packs before feeding 3. which pushes the nipples through openings in the shield. (Page 178 -179 lippincot) INTERVENTION: Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a few drops of expressed milk before feedings. The 2nd is EXPRESSING A LITTLE MILK BEFORE NURSING. Instruct the client to administer perineal care after each voiding 2. not just the nipple NOTE: Do not use soap on the breasts. Warm Tea bags. Rotate the position of the baby for each feeding 3. AIRDRYING THE NIPPLES AND EXPOSING THEM TO THE LIGHT HAVE ALSO BEEN RECOMMENDED. Placing as much of the areola as possible into the neonate’s mouth is one method. WEARING A SUPPORTIVE BRASSIERE DOES NOT PREVENT BREAST ENGORGEMENT. letting the nipples air dry after feedings. Encourage the use of an analgesic spray as prescribed 3. nursing more frequently. Episiotomy 1. and avoiding the use of soap on the nipples. MASSAGING THE BREASTS GENTLY OR TAKING A WARM SHOWER BEFORE FEEDING MAY HELP TO IMPROVE MILK FLOW. POSTPARTUM DISCOMFORTS A. as it tends to remove natural oils. AND FEEDING ON DEMAND to prevent over hunger is helpful. which contain tannic acid also. applying ice compresses just before feedings. also can help overcome inverted nipples 99 . Be sure that the baby is latched on to the areola. Administer analgesics as prescribed if comfort measures are unsuccessful C. Perineal discomfort Apply ice packs to the perineum during the first 24 hours to reduce swelling after the first 24 hours. Using a Woolrich breast shield. In addition. Breast discomfort PREVENTION: The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND FREQUENTLY WITH FEEDINGS. Other methods include changing position with each nursing so that different areas of the nipples receive the greatest stress from nursing and avoiding breast engorgement. and then grasp the nipples to tease them out of the tissue. which make I difficult for the neonate to grasp. will sooth soreness. which increases the chance of cracked nipples NOTE: Inverted Nipples Push the areola tissues away from the nipples. apply warmth by sitz baths B.
2nd breast Feeding AFTER THE FIRST BREAST FEEDING.55% of the calories in breast milk are from fat. NOTE: The condom is the only safe. Breast Feeding The American Academy of Pediatrics recommends beginning breast feeding as soon as possible after delivery or during the first period of reactivity. General Principles/Considerations A. such as Immunoglobulin A. A.Phenylketonuria Routine Screening is done after the neonate has been breast feed for 48 hours. A neonate that will be breast fed should not be given formula by bottle at this time. breast feeding can be done immediately after birth. Cow’s milk is higher in iron. NOTE: Oral contraceptives containing estrogen are not recommended for breastfeeding mothers. progestin-only birth control pills are less likely to interfere with the milk supply 14. the mother should breast feed her infant 2-3 hours until her milk supply is established. COWS MILK According to the American Academy of Pediatrics (AAP) recommends that infants be given breast milk of formula UNTIL 1 YEAR OF AGE. POSTPARTUM DISCHARGE TEACHINGS A. 35% . NOTE: LET DOWN REFLEX OF THE BREAST Oxytoxin is the #1 factor that stimulates the let down reflex while Prolactin is the one that stimulates the acini cells to produce milk. sodium calcium & phosphorus. Because colustrum is not irritating if aspirated and is readily absorbed by the neonate’s respiratory system. which causes the uterine muscles to contract. non prescription contraceptive to use while a woman lactating and before there is normal uterine involution at this time. Hormonal contraceptives may cause a decrease in the milk supply and are best avoided during the first 6 weeks after birth. Baby will develop his or her own feeding schedule. Breast feeding stimulates the oxytocin secretion. Breast milk contents versus cow’s milk BREAST MILK is higher in fat content than cow’s milk. The LATERAL HEEL (HEEL STICK) is the best site because it prevents damage to the posterior tibial nerve and artery and plantar artery. The AAP Committee decreed that cow’s milk could be substituted in the 100 . Many institutions provide sterile water for the initial feeding to assess for esophageal atresia. First Breast Feeding The mother should be encouraged to nurse frequently during the first few days after delivery. Colustrum contains antibodies that the neonate lacks. BREAST FEEDING FOR AT LEAST 7-10 MINUTES PER SIDE FOR THE LET DOWN REFLEX TO BEGIN.
absence of abdominal dissension.The neonate should be held in an upright position and patted on the back.SECOND 6 MONTHS OF LIFE. the infant is less likely to spit up and less likely to swallow air. Store breast milk at the refrigerator for 48 hours or in a freezer for 2 months. or placing the nipple directly in the mouth force the mouth open or force the neonates to take the nipple. Swallowing air can lead to colic. The nurse must determine if the newborn is ready for this feeding. in the middle of the feeding. Such techniques as pulling down on the chin. B. and absence of signs of respiratory distress. the infant will suck less air. BURPING & FEEDING BURPING Another word is bubbling the neonate should be done after 5 minutes of feeding. Frozen breast milk should be thawed in the refrigerator for a few hours. BUT ONLY IF THE AMOUNT OF MILK CALORIES DOES NOT EXCEDD 65% of total calories and iron is replaced by solid foods. C. active bowel sounds. A bottle should never be propped because of the chance of aspiration. and at the end o the feeding. The client should use STERILE PLASTIC CONTAINERS labeled with time. and may cause gastrointestinal tract bleeding SUPPLEMENTING BREAST FEEDING WITH BOTTLED FEEDING Bottle supplements tend to cause a decrease in the breast milk supply and demand for breast feeding. NOTE: Bottle-fed infants are usually fed within the first few hours after birth. then shake it. date and amount. The protein content o cow’s milk is too high. AND SHOULD BE AVOIDED NOTE: Breast milk Storage Never store it in clean glass containers because immunoglobulins tend to stick to glass bottles and the containers should BE STERILE. Burping frequently decreased the chance of spitting up. NOTE: How to stimulate the Infant’s lips to take the nipple? Lightly brushing the neonates lips with nipple causes the neonate to open the mouth the begin sucking. Signs are indicative of readiness for feeding include presence of rooting and sucking reflexes. POSITION FOR FEEDING The neonate should be placed on the right side. squeezing the cheek. and therefore is poorly digested. The nipple should be all the way in the infant’s mouth so the infant can create a good suck. Psychological Adaptation Taking-in Phase Taking-hold Phase Letting-Go Postpartum blues: overwhelming sadness Postpartum depression Postpartum Psychoses Rubin's Postpartum Phases of Regeneration (POSTPARTUM PSYCHOSOCIAL ADAPTATION) 101 . placed under warm tap water. Burping should occur after each 2 oz. NOTE: START OF SOLID FOOD is usually 4 months. placing the patient on prone position has been associated with SIDS (Sudden Infant Death Syndrome) NOTE: If the bottle nipple is kept full of formula.
Pain. Accepts baby as separate person. and warmth accompanied by a firm area in the calf. Maximal stage of learning readiness. chest pain.“TAKING IN” PHASE (DEPENDENT) First 3 Days . • Sleep/food important. • Mother focuses on her own primary needs. Begins to assume the tasks of mothering An optimum time to teach the mother about baby care. Feeling restless accompanied by pallor. • • • • • • • 3-10 days postpartum Mother strives for independence and begins to reassert herself. • Mother may feel deep loss over separation of the baby from part of the body and may grieve over the loss • Mother may be caught in a dependent/independent role.During this time. The primary concern is to meet her own needs. Feeling of full bladder accompanied by inability to void. cool. Mother requires reassurance that she can perform tasks of motherhood. Pain greater than expected. Temperature elevation to 100. food and sleep are a major focus for the client. or blue skin color IV. cough. May cry for no reason. she is ready to learn self-care and infant care skills. pale. rapid heart rate. rapid HR. Bright red vaginal bleeding anytime after birth. clammy skin. wanting to feel safe and secure yet wanting to make decisions • Teenage mothers need special consideration because of the conflict taking place within them as part of adolescence POSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN Increased bleeding. such as sleep and food • Important for the nurse to listen and to help the mother interpret the events of delivery to make them more meaningful • Not an optimum time to teach the mother about baby care “TAKING HOLD” PHASE (DEPENDENT/INDEPENDENT) The client is concerned regarding her need to resume control of all facets of her life in a competent manner. In addition. This phase lasts 1 to 3 days after birth. Mood swings occur. At this time. redness.4º F. feeling of apprehension. and visual disturbance. • Verbalizes about the delivery experience. dizziness. clots or passage of tissue. • Takes place 1-2 days postpartum • Mother is passive and dependent. cold. POST PARTUM COMPLICATIONS 102 . “LETTING GO” PHASE (INTERDEPENCE) • • • • 10 to 6 weeks postpartum Realistic regarding role transition. Difficulty breathing. Enlarging hematoma. concerned with own needs. Shows pattern of life-style that includes the new baby but still focuses on entire family as a unit. she works through the birth experience to sort out reality from fantasy and to clarify any misunderstandings.
B. When assessing for Homan’s sign ask the patient to stretch her kegs out with the knee slightly flexed while dorsiflex the foot. POLYHYDRAMNIOS. This is more common after a csection than after a vaginal delivery.Inflammation of the vein caused by a clot The positive Homan’s sign indicate is possibility of thrombophlebitis or a deep venous thrombosis that is present in the lower extremities. MANIFESTATION • Edematous extremities • Fever with chills • Pain and redness in affected area • Positive Homan’s sign C.A. SIGNS OF HEMORRHAGE • Boggy uterus (does not respond to massage) A boggy uterus would be palpable above the umbilicus and would be soft and poorly contracted. thereby preventing any further bleeding. • Abnormal clots unusual pelvic discomfort or headache • Excessive or bright-red bleeding • Signs of shock Early Hemorrhage starts on the first 24 hours. excessive oxytocin use. Uterine atony and vaginal & cervical tears are associated with early postpartum hemorrhage The #2 cause is OVERDISTENTION OF THE UTERUS from more than (10) pounds. You should assess for uterine atony after a c-section delivery. OTHERS ARE: 4000 gms. Clients who are predisposed are usually MULTIPLE GESTATION. Polyhydramnios and Placental Disorders. It is normal for a patient on magnesium sulfate to feel tired because it acts as a central nervous depressant and often makes the patient drowsy. HEMORRHAGE CAUSES The #1 cause of POSTPARTUM HEMORRHAGE IS RETAINED PLACENTAL FRAGMENTS. INFECTION PREDISPOSING FACTORS • Rupture of membranes over 24 hours before delivery MANIFESTATION • Fever • Chills MANAGEMENT • Antibiotics • Oxytocin MANAGEMENT • Preventive • • • • CURATIVE Immobilize extremity Analgesics Anticoagulant Thrombolytics 103 . • • • • • • MANAGEMENT Fluid replacement Emergency lay Oxygen Vital signs Perineal pad count Psychological support Massaging the lower abdomen after delivery is done to maintain a firm uterus. “BOGGY UTERUS Uterine atony means that the uterus is not firm or it is not contracting. neonate. THROMBOPLEBITIS .. The nurse should gently massage the uterus which will contract the uterus and make it firm. PROLONGED LABOR and LGA (LARGE GESTATIONAL AGE fetus. A positive sign is present when pain is felt at the back of the knee or calf. which will aid in the clumping down of blood vessels in the uterus. or more than 500 ml of blood on the first 24 hrs in a Normal spontaneous delivery.
" Postpartum depression is a psychiatric problem that occurs later in 104 . malaise and localized pain • Engorgement. as may absence of lochia. hardness and reddening of the breasts • Nipple soreness and fissures • Inflammation of the breast as a result of infection • Primarily seen in breastfeeding mothers 2 to 3 weeks after delivery but may occur at any time during lactation NURSING IMPEMENTATION: Instruct the mother in good hand washing and breast hygiene techniques Apply heat or cold to site as prescribed Maintain lactation in breastfeeding mothers Encourage manual expression of breast milk or use of breast pump every 4 hours Encourage mother to support. fever. chills. It can occur up to one month after delivery. Early signs and symptoms of puerperial infection include chills.• Retained placental fragments • Internal fetal monitoring • Vaginal infection • • • • Poor appetite General body malaise Abdominal pain Foul-smelling lochia Puerperial infection is an infection of the genital tract. MASTITIS ASSESSMENT: • Elevated temperature. A foul odor may signal infection. • • • • • • Analgesics Maintain hygiene Semi-fowlers positions Vital signs Early ambulations Assess lochia Bright red blood is a normal lochial finding in the first 24 hours after delivery. breasts by wearing a supportive bra Administer analgesics & antibiotics as prescribed Postpartum Mood Disorders MOOD DISORDERS Postpartum blues ASSESSMENT Onset: 1-10 days postpartum lasting 2 weeks or less • Fatigue • Weeping anxiety • Mood instability Onset: 3-5 days lasting more than 2 weeks • Confusion • Fatigue • Agitation • Feeling of hopelessness and shame “let down feeling” • Alterations in mood “roller coaster emotions” • Appetite and sleep disturbance According to Rubin. tissue fragments. general aching. and flu-like symptoms. Lochia should never contain large clots. dependence and passivity are typical during the Postpartum depression Normal processes during postpartum include the withdrawal of progesterone and estrogen and lead to the psychological response known as "the blues. or membranes.
A client experiencing postpartum depression demonstrates anxiety. anus or ear since all of them are sensitive. Keep newborn with mother to facilitate bonding 5. Observe newborn for signs of hypothermia or hyperthermia 7.postpartum and is characterized by more severe symptoms of inadequacy. Maternal role attainment occurs over 3 to 10 months. Assessment General guidelines 1. abnormal respirations 5. wrap newborn in warm blankets and place a stockinette cap on newborn's head NOTE: Temperature taking The best site without complications is the taking it in axilla. Assess Apgar score 3. Document all abnormal findings 1. Monitor for nasal flaring. 4. Keep newborn warm during the examination 2. Note characteristics of cry 4. Observe or assist with initiation of respirations 2. Implementation 1. retractions. then nares. notifying her physician and conducting a home assessment aren't necessary. It is not advisable to put it in the mouth. or place on mother's abdomen 6. making physical examination difficult. or other signs and symptoms consistently. confusion. Place newborn at mother's breast if breastfeeding is planned. then perform assessments that are least disturbing to the newborn first 3. Onset: 3-5 days postpartum • Symptoms of depression plus delusions • Auditory hallucinations • Hyperactivity SECTION VII PHYSIOLOGIC STATUS OF NEWBORN NOTE: The best time for physical assessment is midway between feedings. irritable. with bulb syringe 2. A. The hungry is often fussy. Obtain vital signs 6. Suction mouth. Attachment also is an ongoing process that occurs gradually. Manipulation after eating may cause the neonate to regurgitate or vomit. Dry newborn and stimulate crying by rubbing 3. Postpartum psychosis taking-in period. grunting. Because the client's behavior is normal. Initiate nursing interventions for abnormal findings 4. Maintain temperature stability. Begin with general observations. 1. Place newborn in warmer INITIAL PHYSICAL EXAMINATION & CARE OF THE NEWBORN 105 . which may last up to 3 days after delivery. Assess for gross anomalies 2.
m.m. Head circumference: 33 to 35.p. A score of 3 to 6 is considered moderately depressed c. Grimace Some flexion Slow. A score of 0 to 2 is severely depressed .5 to 9. Heart rate: 100 to 170 beats per minute (apical). Respirations: 30 to 80 breaths per minute. Length: 45 to 55 cm (18 to 22 inches) 2.indicates that the newborn needs assistance. Position newborn on side or abdomen or in modified Trendelenburg position to facilitate drainage of mucus 8. Conduction of heat away from the body may occur when the neonate comes in direct contact with cold surfaces such as scale or cold stethoscope. irritability. Assess each of five items to be scored. Radiation and Evaporation Evaporation occurs when wet surfaces such as neonate’s skin are exposed to air. Convection. respiration and heart rate.8 to 99° F 4. Weight: 2500 to 4300 g (5. If the score is less than 7 at 5 minutes. 1. and assign value of 0 (very poor) to 2 (excellent) for each item 4. extremities blue Less than 100 b. Add the points to determine the newborn’s total score a. A score of 7 to 10 indicates a health -indicates that the newborn is doing well. Axillary temperature: 96. Place matching identification bracelets on mother and newborn NOTE: Convection. Body measurements 1.7. Footprint newborn and fingerprint mother on identification sheet. 1. Blood pressure: 73/55 mm Hg 4. Vigorous cry Actively moves Good cry The components of Apgar scoring system are tone. irregular 2 Totally pink Over 100 b.p. the Apgar score should be performed at 10 minutes 3. per agency policies and procedures 10.5 cm (13 to 14 inches) 106 .keeping away the neonate from the air conditioning or cooling ducts prevents heat loss 3. Radiation is the transfer o heat to cooler objects that are not in direct contact with the neonate. Perform and record the Apgar score at 1 minute and at 5 minutes 2. color. Conduction. Ensure newborn's proper identification 9. assess for a full minute because of irregularities afterbirth 2.5 pounds) 3. Vital signs APGAR CRITERIA APGAR SCORE COLOR HEART RATE REFLEX IRRITABILITY MUSCLE TONE RESPIRATORY EFFORT O Pale Absent No response Limp Absent 1 Body pink. assess or a full minute 3. b.
m. burped. Chest circumference: 30 to 33 cm (12 to 13 inches) and should be equal to or 2 to 3 cm less than the head circumference NOTE: Neonates Head versus Chest circumference At birth. but anatomic or permanent closure may take several months • HEART RATE averages 140 b.p. or occurs during or immediately after feeding.4. gentle stimulation is sufficient to get the infant to breathe RENAL SYSTEM RESPIRATORY STATUS • Urine present in the bladder at birth but NB may not void doe 1st 12-24 hours • Later pattern is 6-10 voidings/ day – indicative of sufficient fluid intake • Urine is pale and straw colored – initial voidings may leave brick-red spots on diaper ( d/t passage of uric acid crystals in urine) • Infant unable to concentrate urine for the 1st 3 months DIGESTIVE SYSTEM • IMMATURE CARDIAC SPHINCTER – may allow reflux of food. average Chest circumference is 12.Newborns may nurse vigorously immediately afterbirth or may need as long as several days to suck effectively .placed NB right side after feeding • Newborn can’t move food from lips to pharynx. • BP 73/55 mmHg • PERIPHERAL CIRCULATION acrocyanosis within 24 hours • RBC high immediately after birth. Usually. REGURGITATE. while regurgitation has no sour odor or curdling of milk. prevent alveolar collapse and respiratory distress syndrome • RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for 1 full minute change noted during sleep or activity NOTE: Periodic apnea is common in preterm infants.5 to 14 inches ( 31-35 cm) B . The Average Head circumference is 13 -14 inches (33-35 cm) . bottle-fed 107 . Insert nipple well to mouth • FEEDING PATTERS vary . Head to Toe Newborn Assessment CIRCULATORY STATUS • UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord id clamped • DUCTUS ARTERIOSUS constrict with establishment of respiratory function • FORAMEN OVALE closes functionally as respirations established. with a sour odor. looks like curdled milk due to HCL.Provide support and encouragement to new mothers during this time as infant feeding is very emotional doe most mothers NOTE: Distinguishing Neonatal Vomiting from Regurgitation Vomiting is usually sour. falls after 1st week • ABSENCE/ NORMAL FLORA INTESTINE Vitamin K • Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung function. IMPORTANT CONSIDERATIONS: • Breastfeeding can usually begin immediately after birth. the neonates head circumference is about 2cm LARGER THAN THE CHEST CIRCUMFERENCE.
tarry residue from lower intestine .8 to 99F . • FIRST STOOL is MECONIUM .7 – 55.A special structure in NB is a source of heat . . 13 oz.Black. brownish green in color After 3 days MILK STOOLS are usually passed a. and unable to shiver to increase body heat. giving a jaundiced or yellow appearance to these tissues TEMPERATURE • HEAT PRODUCTION in newborn accomplished by: Metabolism of “ BROWN FAT” .9 cm.Axillary temperature: 96. TRANSITIONAL STOOLS thin.Usually passed within 12-24 hours after birth If the amniotic fluid shows evidence of meconium staining. – 8 lbs.formed and pale yellow HEPATIC • Liver responsible for changing Hgb into conjugated bilirubin.Increased metabolic rate and activity . MILK STOOLS for BF infant – loose and golden yellow b.Cold stress increases o2 consumption – may lead to metabolic acidosis and respiratory distress • NB develops own antibodies during 1st 3 months but at risk for infection during the first 6 weeks • Ability to develop antibodies develops sequentially IMMUNOLOGIC Neonatal Physical Assessment • • Birth weight=2500-400 grams (5 lbs. the physician most likely do immediately after delivery is to suction the oropharynx immediately after the head is delivered and before the chest is delivered. an infant should begin to receive solid food foods one at a time and 1 week apart. which is further changed into conjugated (water soluble) bilirubin that can be excreted Excess unconjugated bilirubin can permeate the sclera and the skin. MILK STOOLS for FORMULATED FED. 8oz.NB’s body temperature drops quickly after birth – after stress occurs easily . (18-22 inches) 108 .Body stabilizes temperature in 8-10 hours if unstressed . At age4-6 months.newborns may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after birth prior to a feeding with formula • An infant with gastrostomy tube should receive a pacifier during feeding unless contraindicated to provide normal sucking activity and satisfy oral needs.) Length= 45.Newborn can’t shiver as an adult does to release heat Newborns are unable to maintain a stable body temperature because they have an immature vasomotor center.
Greater than chest circumference) • Anterior fontanel (diamond shape) = closes 12-18 months • Posterior fontanel (triangle shape)= closes 2-3 months NOTE: The posterior fontanel is located at the intersection of the sagittal and lambdoid suture is the space between the pariental bones. can occur in any labor and isn't limited to a prolonged second stage of labor.asymmetry of head as a result of pressure in birth canal Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the baby's scalp during labor. Lacrimal glands immature at birth. tearless cry up to 2 months Absence of tears is common because the neonate’s tear glands are not yet fully developed Transient strabismus Doll’s eye reflex persist for about ten days Red Reflex: A red circle on the pupils seen when an ophthalmoscope’s light is shining onto the retina is a normal finding. scaphoid appearance indicates diaphragmatic hernia Umbilical cord is white and gelatinous with two arteries and one vein and begins to dry within 1-2 hours after delivery NOTE: Umbilical cord 109 . which is simply soft tissue edema of the scalp. Caput succedaneum. the lambdoid suture separates the two parietal bones and the occipital bone Molding. NOSE MOUTH EARS NECK CHEST Nose breathers for first few months of life Scant saliva with pink lips Epstein’s Pearls .HEAD Head circumference=33-35 cm (2-3 cm. EYES Blue/ gray d/t scleral thinness. This indicates that the light is shining onto the retina . Blood outside the vasculature in a newborn increases the possibility of jaundice as the newborn's body tries to reabsorb the blood .small shiny white specks on the neonate’s gums and hard palate which are normal Incurving of pinna and cartilage deposition Short and weak with deep fold of skin Characterized by cylindrical thorax and flexible ribs NOTE: • • • appears circular since anteroposterior and lateral diameters are about equal Respirations appear diaphragmatic Nipples prominent and often edematous Milky secretion (witch's milk) common ( effect of estrogen) • ABDOMEN Cylindrical with some protrusion. CONVERGENT STRABISMUS (CROSS EYED) It is common during infancy until age 6 months because of poor oculomotor coordination NOTE : Congenital Glaucoma Unequal size should be reported immediately. permanent color established w/in 3-12 mos.
in cord. clamp can be removed hen the cord is dried and occluded Umbilical clamp can be removed after 24 hours MALE: includes rugae on the scrotum and testes descended into the scrotum Urinary meatus: • Hypospadias (ventral surface) • Epispadias (dorsal surface) NOTE: • Meatus at tip of penis • Testes descended but may retract with cold • Assess for hernia or hydrocele • First voiding should occur within 24 hours • • Pseudomenstruation possible (blood-tinged mucus) effect of estrogen First voiding should occur within 24 hours FEMALE: labia majora cover labia minora and clitoris EXTREMITIES All neonates have bowlegged and flat feet NOTE NORMAL FEATURES: Major gluteal folds even Creases on soles of feet Assess for fractures (especially clavicle) or dislocations (hip) Assess for hip dysplasia. no clicks should be heard Some neonates may have abnormal extremities: • Polydactyl (more than 5 digits on extremity) • Syndactyl (two or more digits fused together) 110 . thin cord may be associated with poor fetal growth Assess for intact cord. two arteries and one vein. when thighs are rotated outward. if fewer than three vessels are noted notify the physician Small.• • • • • GENITALIA Three vessels. and ensure that damp is cured Cord should be clamped for at least the first 4 hours after birth.
and it disappears after birth ( page 199 lippincot) Never remove it with alcohol or cotton balls. for example bluish hands and feet due to neonates being cold or poor perfusion of the blood to the periphery of the body. arms shoulders or other areas. followed by the hands and feet. because it is a protective layer of the neonate after birth. . spreads to the chest. chest or tip of the nose. Epstein’s pearls are small. unless meconium skinned. tongue and trunk indicating HYPOXIA which needs further assessment by the nurse. blue or black marks that are frequently found on the sacral area.Figure. Milia are blocked sebaceous glands located on the chin and the nose of the infant. Acrocyanosis versus Central Cyanosis Acrocyanosis involves the extremities of the neonate. Possible causes of early jaundice are blood incompatibility. NOTE: Vernix Caseosa Erythema toxicum neonaturum Telangiectasia Port wine stain (nevus flamus) Strawberry hemangioma Hemangioma is benign vascular tumor that may be present on the newborn SKIN 111 . NOTE: Jaundice starts at the head first. while those on the other side of the body dilate. which are the last to be jaundiced. then the abdomen. and severe hemolytic process. Polydactyl and Syndactyl SPINE Should be straight and flat Anus should be patent without any fissure Dimpling at the base is associated with spina bifida A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS damage Assessment for Jaundice The #1 technique is to blanch the skin over the bony prominence such as the forehead. Harlequins Sign Occurs on one side of the body turns deep red color. Jaundice in the first 24 hours after the birth is a cause for concern that requires further assessment. It occurs when blood vessels on one side constrict. oxytocin induction. buttocks. They are nor abnormal and will disappear shortly after birth. Acrocyanosis of the hands and feet is normal. resulting from sluggish peripheral circulation Mongolian Spots Gary. which involves the lips. While central cyanosis. then the arms and legs. Hemangiomas / Vascular Tumors Nevi flammeus or port wine stains VERNIX CASEOASA Should not be removed by oil or hand lotion. white cysts on the hard palate or gums of the newborn.
NEWBORN REFLEXES 112 .GESTATIONAL ASSESSMENT PARAMETER EAR BREAST TISSUE FEMALE GENITALIA MALE GENITALIA HEEL CREASES NURSING ACTION Fold the pinna (auricle) forward Measure it Observe Observe Observe ‘TERM’ born between 37-42 weeks gestation Pinna recoils (springs back) 3 mm Labia majora cover labia minora Scrotal sac very wrinkled Extend 2/3 of the way from the toes to the heel ‘PRETERM’ born before 37 weeks gestation Pinna opens slowly or stays folded in very premature infants Less than 3 mm Labia minora are more prominent.Figure 24 Hemangioma Figure 25 Erythema toxicum neonaturum and Milia C. vaginal opening can be seen Fewer shallow rugae on the scrotum Soles are smoother. creases extend less than 2/3 of the way from the toes to the heel D.
then the examiner moves the fingers along the ball of the foot • The newborn’s toes hyperextend while the big toe dorsiflexes • Reflex disappears after the newborn is 1 year old • Absence of this reflex indicates the need for a neurological examination The newborn simulates walking. looking for food. This reflex disappears by 6 weeks. Palmar response lessens within 3-4 months Palmar response lessens within 8 months Rooting and sucking reflex usually disappears after 3-4 months but may persists for up to 1 year • Symmetric & bilateral abduction & extension of arms and hands • Thumb & forefinger form a C • “EMBRACE” reflex • Present at birth. the neonate's fingers close around it. gently stroke upward along the lateral aspect of the sole. A neonate will fan his toes. The Babinski reflex is elicited by stroking the neonate's foot. on the side of the sole. Other options refer to other reflexes seen in neonates: The palmar grasp reflex is elicited by placing an object in the palm of a neonate. This reflex disappears between ages 6 and 9 months. gently and quickly turn the head to one side 113 . The sucking reflex is seen when the neonate's lips are touched and lasts for about 6 months. until about age 3 months. alternately flexing and extending the feet The reflex is usually present 3-4 months • While the newborn is falling asleep or sleeping. PALMAR GRASP REFLEX Newborn’s fingers curl around the examiner’s fingers and the newborn’s toes curl downward. It results in drawing up the legs. from the heel toward the toes. producing a positive Babinski sign. an embracing position of the arms. and usually a short cry. ROOTING REFLEX MORO REFLEX BABINSKI’ SIGN STEPPING OR WALKING REFLEX TONIC NECK REFLEX Figure 26 Moro Reflex or Embrace Reflex • Beginning at the heel of the foot.The rooting reflex is elicited by stroking the neonate's cheek or stroking near the corner of the neonate's mouth. complete response may occur up to 8 weeks • A persistent response lasting more than 6 months may indicate the occurrence of brain damage during pregnancy A normal reflex in a young infant caused by a sudden loud noise. The neonate turns the head in the direction of the stroking.
BASIC TEACHING NEEDS OF NEW PARENTS CORD CARE • Cleanse the cord with alcohol and sometimes triple dye once a day • Keep the area clean and dry • Keep the newborn’s diaper below the cord to prevent irritation • Signs of infection: redness. Other agents such as wipes. The reflex usually disappears after about 6 weeks E. CIRCUMCISION CARE BONDING • • • • • • • Observe for bleeding. the left arm & leg extend outward while the right arm & leg flex • When the head is turned to the right side. the right arm & leg extend outward while the left arm & leg flex • Usually disappears within 3-4 months a. sterile water and soap & water are not as effective as alcohol. because there are a lot of bacteria which is resistant against some bacteria. The umbilical cord dries and falls off about 14 days. and sing to infant Promotes skin-to-skin contact between parent and infant Feedings are opportunities for parent-infant bonding Notify physician for signs of infection NOTE: Sense of Touch The most highly developed sense at birth that is why. odor • Notify physician for signs of infection NOTE: • Note any bleeding or drainage from the cord • Triple dye may be applied for initial cord care because it minimizes microorganisms and promotes drying. The alcohol promotes drying and helps decrease the risk of infection. first urination Apply diaper loosely to prevent irritation Notify physician for signs of infection Encourage parent to talk to. Place the newborn on the abdomen b. 114 . hold. one time. swelling. drainage. use a cotton-tipped applicator to paint the dye. Peroxide and lanolin promote moisture. The newborn begins making crawling movements with the arms and legs c. Water doesn’t promote drying. on the cord on 1 inch of surrounding skin • Application of 70% isopropyl alcohol to the cord with each diaper change and at least two r three times a day to minimize microorganisms and promote drying.CRAWLING • As the newborn faces the left side. It is best to care for the neonate’s umbilical cord area by cleaning it with cotton pledgets moistened with alcohol. An antibiotic ointment maybe used instead of alcohol. NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area. neonates responds well to touch. which can inhibit drying and allow growth of bacteria.
earlobe and premature female genitalia PRE TERM INFANT Definition PRE TERM INFANT A neonate born before 38 weeks age of gestation Synonym Low birth weight (Mosby’s Comprehensive Review of Nursing for NCLEX-RN page 215) Low socioeconomic level Poor nutritional status Lack of pre natal care Contributing factors 115 .Figure 27 Premature infants sole creases.
020. Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn to establish clear airway. The normal range for blood glucose level in a preterm baby is 40 to 60 mg/dl. Cardinal signs Multiple pregnancy Prior previous early birth Race (non whites have a higher incidence of prematurity than whites) Cigarette smoking The age of the mother ( the highest incidence is in mother’s younger than age 20. Best procedure Best position Positioning the infant on the back with the head of the mattress elevated approximately 15 degrees to allow abdominal contents to 116 . The normal specific gravity for a preterm baby is 1. Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own.) Order of birth ( early termination is highest in first pregnancies and in those beyond the forth ) Closely spaced pregnancies Abnormalities of the reproductive system such as intrauterine septum Infections ( specially urinary tract infections) Obstetric complications such as premature rupture of membranes or premature separation of the placenta Early induction of labor Elective cesarian birth Abnormal laboratory values Appears small and underdeveloped The head is disproportionately large ( 3 cm or more greater than chest size) Skin is thin with visible blood vessel and minimal subcutaneous fat pads Vernix caseosa is absent Both anterior and posterior fontanelles are small Decreased RBC’s Decreased serum glucose Increased concentration of indirect bilirubin Decreased serum albumin NOTE: The normal range of urine output for a preterm baby is 1 to 2ml/kg/day. Intubations NOTE: head of the infant in neutral position with towel under shoulder.
Preterm size laryngoscope ET tube Suction catheter with synthetic surfactant Isolettes (incubator) Naloxone (Narcan) Nature of the drug: Narcotic antagonist Side effects: Hypertension. Tetracycline 1% Silver Nitrate 1% ( not already used – causes chemical conjunctivitis) Prophylactic measure to protect against Neisseria gonorrhoeae and Chlamydia trachomatis Side effects: Silver nitrate can cause chemical conjuctivitis Impaired gas exchange related to immature pulmonary functioning Risk for fluid volume deficit related to insensible water loss at birth and small stomach capacity Risk for aspiration related to weak or absent gag reflex a nd/or administration of tube feedings Bedside equipment Drug study 2. Complications Anemia of prematurity Hyperbilirubinemia/ kernicterus Persistent patent ductus arteriosus Periventricular / intraventricular hemorrhage Respiratory distress syndrome Retinopathy of prematurity Retrolental fibroplasias are a complication that occurs if the infant is overexposed to high oxygen levels. 4. Nursing diagnosis 1. 3. Best position for suctioning: Infant on the back and slide a folded towel or pad under shoulders to rise. rales Vitamin K (Aquamephyton) Use for prophylaxis to treat hemorrhagic disease of the newborn. 117 .5% Ilotycin. tachycardia Surfactan ( Survanta) Nature of the drug: Lung surfactant to improve lung compliance Side effect: Transient bradycardia.fall away from the diaphragm affording optimal breathing space. head is in neutral position. Side effects: Hyperbilirubinuria Eye prophylaxis (Erythromycin 0. 3. 2. Necrotizing enterocolitis 1. irritability.
stasis of respiratory secretions. suction catethers and synthetic surfactant to be administered by the endotracheal tube. (Mosby’s Comprehensive Review of Nursing for NCLEX-RN page 216) POST TERM INFANT 118 . and/ or aspiration 6. • Bedside larngyoscope. • Give the mother oxygen by mask during the birth to provide the preterm infant with optimal oxygen saturation at birth ( 85-90%). humidity and oxygen concentration. • Arrange follow-up before and after discharge by a visiting nurse. Infant must be kept warm during resuscitation procedures so he or she is not expending extra energy to increase the metabolic rate to maintain body temperature. administer oxygen only if necessary • Maintain aseptic technique to prevent infection • Adhere to the techniques of gavage feeding for safety of infant • Observe weight-gain patterns • Determine blood gases frequently to prevent acidosis. Risk for infection related to immature immune response. ( Mosby’s Comprehensive Review of Nursing for NCLEX-RN page 216) • The nurse’s first priority in preparing a safe environment for a preterm newborn with low Apgar scores is to prepare respiratory resuscitation equipment. Institute phototherapy when hyperbilirubinemia occurs • Support parents by letting them verbalize and ask questions to relieve anxiety. • Keeping maternal analgesia and anesthesia to a minimum also offers the infant the best chance of initiating effective respiration.4. Nursing intervention Hypothermia related to lack of subcutaneous and brown fat deposits. allow them to participate in care. endotracheal tube. large body surface area in relation to body weight. color and vital signs • Check efficacy of Isolette: maintain heat. inadequate shiver response. and/or lack of flexion of extremities toward the body. • Observe for changes in respirations. 5. Airway maintenance is the first priority. Imbalanced nutrition: less than body requirements related to lack of energy to suck and/or weak or absent sucking reflex. • Provide liberal visiting hours for parents. immature thermoregulation center.
dehydrations and chronic hypoxia “old man faces’ Long & thin with cracked skin which is loose. wrinkled and strained greenish yellow. a developmental approach to comprehensive cgfns and nclex review.) Mother’s with diabetes mellitus Congenital abnormalities such as omphalocele. with no vernix nor lanugo Long nails with firm skull Wide eyed alertness of one month old baby Maternal & child nursing. Body is covered with lanugo Old man facies Intrauterine weight loss. Page 131 Abnormal laboratory values Screening test Inc Inc De 119 . 5th ed.Figure 28 Definition P Contributing factors O S T T E R M I N F A N T A Classic signs Low socioeconomic level Poor nutritional status Lack of pre natal care Multiparous mother’s Cigarette smoking The age of the mother (the highest incidence is in mother’s younger than age 20.
5% Ilotycin.Best procedure So Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own. Tetracycline 1% Silver Nitrate 1% Prophylactic measure to protect against Neisseria 1. NOTE: The infant who are exposed to high blood-glucose levels in utero may experience rapid and profound hypoglycemia after birth because of the cessation of a high in-utero glucose load. congenital anomalies. Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn. polycythemia. NOTE: The patient with post-term pregnancy is at high risk for decreased placental functioning. therefore increasing the risk of inadequate oxygen circulation to the fetus Bedside equipment Drug study E Su Eye prophylaxis (Erythromycin 0. Vitamin K (Aquamephyton) Use for prophylaxis to treat hemorrhagic disease of the newborn Side effects: Hyperbilirubinuria Meconium aspiration syndrome Respiratory distress syndrome 120 . Best position Complications Po NOTE: Post mature neonates have difficulty maintaining glucose reserves. To establish clear airway. seizure activity and cold stress. The small-for-gestational-age infant has use up glycogen stores as a result of intrauterine malnutrition and has blunted hepatic enzymatic response with which to carry out gluconeogenesis. Intubations NOTE: head of the infant in neutral position with towel under shoulder. Other common problems include Meconium aspiration syndrome.
gonorrhoeae and Chlamydia trachomatis Side effects: Silver nitrate can cause chemical conjuctivitis Nursing diagnoses 1. Ineffective airway breathing 2. Risk for fluid volume deficit related to insensible water loss at birth 3. Ineffective infant feeding pattern 1. Assess newborn’s respiratory rate, depth and rhythm. Auscultate lung sound. Note: Meconium stained syndrome of POST MATURE neonates Aspiration of meconium is best prevented by suctioning the neonate’s nasopharynx immediatelt after the head is delivered and before the shoulders and chest are delivered. As long as the chest is compressed in the vagina, the infant will not inhale and aspirate meconium in the upper respiratory tract. Meconium aspiration blocks the air flow to the alveoli, leading to potentially life threatening respiratory complications. 2. 3. Anticipate the infants need to be breastfeed Demonstrate technique for feeding to mother, note proper positioning of the infant, “latching on” technique, rate of delivery of feeding and frequency of burping Provide a relaxed environment during feeding Adjust frequency and amount of feeding according to infants response Alternate feeding procedure (nipple and gavage feeding) according to infants ability. Administer IV fluids after birth to provide Glucose to prevent hypoglycemia, monitor closely the infusion rate. Kept the infant under a radiant heat warmer to preserve energy Monitor baby’s weight, serum electrolytes and ensure adequate fluid intake Measure urine output by weighing diapers Check for blood stools to evaluate for possible bleeding from intestinal tract. Keep a restful environment. Suction every 2 hours or more often as necessary Position newborn on side or back with the neck slightly extended Administer O2, anticipate the need for CPAP or PEEP Continue to assess the newborn’s respiratory status closely. Encourage as much parental participation in the newborn’s care as condition allows
Monitor mother’s effort, provide feedback and assistance as needed Suggest mother to monitor infants weight periodically
OTHER NEW BORN ABNORMALiTIES A. RESPIRATORY DISTRESS SYNDROME - Delay in lung maturation and deficiency in surfactant - Common among cesarean birth and low birth weight - A serious lung disease immaturity and inability to pre-resulting in hypoxia and acidosis NOTE: More common in neonates delivered by cesarean section than in those delivered vaginally.
COMMON SIGNS Cyanosis, dyspnea, sternal and/or costal retractions, tachypnea, grunting, and nasal flaring, flaring nares, Expiratory grunting MANAGEMENT Maintain a patent airway, place the infant in a warm isollete with oxygen, administer antibiotics as prescribed and correct acidosis
B. HEMOLYTIC DISEASE - ABO or Rh incompatibility COMMON SIGNS - Jaundice in 24 hours of life, signs of anemia (restlessness, fatigue, anorexia) enlargement of liver and spleen and increase in bilirubin levels PREVENTION INDIRECT COOMB’S TEST - Tests for anti-Rh (+) Ab in mother’s circulation - Performed during pregnancy at first visit & again about 28 week’s gestation RESULTS: - If (-) at 28 weeks, a small dose of (MicroRhogam) is given prophylactically to prevent sensitization in the 3rd trimester. - Rhogam may also be given after 2nd trimester amniocentesis - If (+), levels are titrated to determine potential effects on the fetus DIRECT COOMB’S TEST - Tests done on the cord blood at delivery to determine presence of (+) Ab on fetal RBC’s RESULTS - If both indirect & direct Coomb’s test is NEGATIVE & infant is Rh (+) - NEGATIVE: No formation of Anti-Rh (+) Ab - Rhogam (Rho [D] human immune globulin is given to the Rh (-) mother to prevent development of anti-Rh (+) Ab as the rest of sensitization from present/just terminated pregnancy.
C. HYPERBILIRUBINEMIA - Serum bilirubin greater than 15 mg/dl within first 24-36 hours of life are alarming - At any serum bilirubin level, jaundice during the first day of pathological process Evaluation is indicated when serum: over 12 mg/dL in the term newborn Therapy is aimed at preventing results in permanent neurological damaging from the deposition of bilirubin in cells TREATMENT:
The goal of phototherapy is to decrease the serum unconjugated bilirubin level because a high level may lead to bilirubin encephalopathy (kernicterus). Phototherapy doesn't prevent hypothermia or promote respiratory stability. It has no effect on conjugated bilirubin, a water-soluble substance easily excreted in urine and stool. Phototherapy increases gastric motility, causing the infant to have many green, watery stools. The increased gastric motility also causes the infant to be irritable. There is no evidence that the newborn has a lactose intolerance or malabsorption problem, nor is there evidence that the newborn's bilirubin levels are rising to dangerous levels. NOTE: The phototherapy lights must be turned off when serum bilirubin levels are drawn because the light decreases the bilirubin levels in the test tube, and the result reported wouldn’t be accurate. The infant should be repositionec at least every 2 hours to permit the light to reach all skin surfaces. The infant’s intake should be increased to compensate for the fluid loss through the skin and the loose stools. The eye patches are removed with every feeding, and the eyes are assessed for conjunctivitis every 8 hours.
NURSING IMPLEMENTATION: • Expose as much of the newborn's skin as possible • Cover the genital area, and monitor genital area for skin irritation or breakdown ( priapism may occur) • Cover the newborn's eyes with eye shields or patches; make sure eyelids are closed when shields or patches are applied • Remove the shields or patches at least once per shift to inspect the eyes for infection or irritation and to allow eye contact • . Measure the quantity of light every 8 hours • Monitor skin temperature closely • Increase fluids to compensate for water loss • Expect loose green stools and green urine • Monitor the newborn's skin color with the florescent light turned off, every 4 to 8 hours
Monitor the skin for bronze baby syndrome, a grayish brown discoloration of the Reposition newborn every 2 hours
ERYTHROBLASTOSIS FETALIS • • • Rh antigens from the baby's blood enter the maternal bloodstream Destruction of RBCs those results from an antigen antibody reaction Exchange of fetal and maternal blood takes place primarily when the placenta separates at birth The mother produces anti-Rh antibodies against the fetal blood cells
increase ICP. Irritability. loud and lusty cry NURSING INTERVENTION: 1. Abnormal palmar creases. The newborn may be jittery and hyperactive. Congenital heart disorders. Seizures. Paternal blood type might be determined for the pregnant RH negative woman in order to help determine fetal blood type. Position newborn on side to facilitate drainage of secretions 124 . all infants will be RH positive. NOTE: Heroin withdrawal neonates High pitch cry. RHoGAM blocks antibody production by attaching to fetal RH positive blood cells in the maternal circulation before an immunological response is initiated. and Moro’s reflex is decreased. Hypoplastic philtrum. 2. short. Implementation 1. there is a 50% chance of an RH negative infant. the Rh-negative blood is replaced with the baby's own blood gradually NOTE: The RH negative mother who has no titer (negative Coombs’ test results. Tendon reflexes are increased. If the father of future fetuses is RH positive heterozygous. upturnednose.• • • Antibodies are harmless to the mother but attach to the erythrocytes in the fetus and cause hemolysis Sensitization is rare with the first pregnancy ABO incompatibility is usually less severe B. Flat midface Thin upper lip. if he is RH positive homozygous. Administer Rho(D) immune globulin to the mother during the first 72 hours after delivery if the Rhnegative mother delivers an Rh-positive fetus but remains unsensitized The baby's blood is replaced with Rh-negative blood to stop the destruction of the baby's red blood cells. Jaundice that develops rapidly after birth and before 24 hours (PATHOLOGICAL JAUNDICE) C. The cry is often shrill and persistent with yawning and sneezing. hypersensitivity to stimuli.. cyanosis). Low nasal bridge. Respiratory distress [apnea. hypoglycemia. Tremors Poor feeding. hyperbilirubinemia & hemolytic anemia 2. THE ADDICTED NEWBORN NOTED FEATURES: Short palpebral fissures. NOTE: These are signs of Heroine withdrawal usually occurs within 24 to 48 hours of birth. Assessment 1. Monitor for respiratory distress 2. non sensitized) and who has delivered an RH positive fetus is given an intra muscular injection of anti-RH (D) (RHoGAM). RHoGAM must be administered to unsensitized postpartum women after the birth of each RH positive infant to prevent production of antibodies.
Administer IV glucose to treat necessary and as prescribed 6. Description: A neonate who is plotted at or below the 1Oth percentile on the intrauterine growth curve NOTE: #1 Predisposing factor is Maternal Smoking 125 . COMPLICATIONS: High incidences of hypoglycemia. Monitor for edema 7. and nasal flaring NOTE FOR CHARACTERISTICS OF HYPOGLYCEMIA: Abnormally low level of glucose (less than 30 mg/dL in the first 72 hour 45 mg/dL after the first 3 days of life N 2. such as twitching. and cyanosis Hyperbilirubinemia Signs of respiratory distress. Assess suck and swallow reflex 6. Monitor weight 4. cyanosis. Monitor weight and head circumference (Check for Increase ICP) 10. Monitor for hypoglycemia 5. Description Neonate born to an insulin-dependent mother or gestational diabetic mother and with high incidence of congenital anomalies. breast milk. NEW BORN OF DIABETIC MOTHER A. Decrease environmental stimuli 11. Suction as necessary 8. difficulty in feeding. respiratory distress. lethargy. and hyperbilirubinemia B. seizures. Monitor I & 0 9. Normal blood glucose level is 40 to a 1-day-old neonate and 50 to 90 neonate older than 1 day • Increased respiratory rate • Twitching. The use of narcotic antagonists to reverse respiratory depression in the drug addicted neonate is contraindicated because these drugs may precipitate acute withdrawal in the neonate. apnea. Assessment • • • • • MACROSOMIA & LGA as a result of excess fat and glycogen in tissues Edema or puffiness in the face and cheeks Signs of hypoglycemia. with 10% glucose in water.3. or formula as prescribed 5. retractions. grunting. Monitor for signs of respiratory distress 2. Feed early. Administer small feedings and burp well 7. Monitor for tremors & seizures SMALL FOR GESTATIONAL AGE A. Keep resuscitation equipment at the bedside 4. nervousness. or tremors • Unstable temperature • Cyanosis NURSING INTERVENTION: 1. such as tachypnea. Monitor bilirubin and blood glucose levels 3. hypocalcemia.
Signs of infection 8. Lowered or elevated body temperature 4. Gestational age and physical maturity 3. NERVOUS SYSTEM ANOMALIES . A common complication of the SGA newborn immediately after birth is hypoglycemia because of the increased metabolic rate in response to heat loss and poor hepatic glycogen stores. The SGA newborn may also have suffered intrauterine hypoxia. Monitor for infection and initiate measures to prevent sepsis 5. in which the spinal cord and associated membranes protrude through a gap in the laminae of the vertebrae. which depletes glucose. Maintain body temperature 3. Maintain airway 2. Fetal distress 2. Cyanosis c.B. Monitor blood glucose levels and for signs of hypoglycemia 6.Myelomeningocele type of spina bifida. C. Signs of polycythemia: a. Spina bifida occulta Meningocele Myelomeningocele Meningocele Myelomening 126 . Ruddy appearance b. Hypoglycemia 6. Provide stimulation. SPINA BIFIDA Synonyms Definition Types Spinal Dysraphia Refers to malformation of spine in which the posterior portion of the laminae of the vertebrae fails to close. Physical abnormalities 5. Signs of aspiration of meconium NOTE: Obtaining a blood sample to determine glucose level would have the highest priority to on SGA. Initiate early feedings and monitor for signs of aspiration 7. Implementation 1. Assessment 1. Jaundice 7. such as touch and cuddling A. Observe for signs of respiratory distress 4.
ocele ( meningom yelocele) Spina bifida occulta 127 .
Sacs are covered by thin membrane & nerve are exposed Neurologi cal deficits are evident Meninges or protective covering around the spinal cord has pushed out through the opening in the vertebrae in a sac. Textbook of Basic Nursing Lippincott 6th ed. Spinal cord intact Neurologi cal deficit are usually NOT PRESENT Can be 128 .( p. 898.)One of the meninges (the Spinal cord covering) protrudes or herniated through opening in vertebral column.) Protrusio n of the spinal cord protrudes through the back. Most Description severe form of spina bifida . 898. (p. Textbook of Basic Nursing Lippincott 6th ed.
7. Keep the infant clean esp. Provide skin care especially ankles. Avoid positioning on the infant's back to prevent pressure on the sac. 8. Do not place any covering directly over the sac. 9. Preventing Infection 1. Use foam or fleece pad to reduce pressure of the mattress against the skin. Place a foam rubber pad/ small pillow or roll diaper between the infant’s legs to maintain hips in abduction & to prevent or counteract subluxation. Observe sac for evidence of irritation or leakage of CSF 4. irritability. Avoid touching the sac. 2. 5. oozing of fluid or pus from the sac) Note: Same w/ Meningcele 129 . knees. buttocks & genitalia 3. Provide passive range of motion exercise. Use prone position w/ hips slightly flexed to decrease tension on the sac. 3. Risk for Infection related to contamination Nursing Interventions: Protecting the skin integrity 1. tip of nose.Nursing Diagnosis and Interventio n Impaired skin Integrity related to impaired motor & sensory function. cheeks & chin. Keep area clean from urine and feces 2. 6.( fever. Apply sterile gauze /moistened towel and watch for any signs of infection. lethargy.
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