MATERNAL & CHILD NURSING

(CARE OF THE HEALTH / AT RISK MOTHER AND CHILD)

By: Gemky R. Eusebio, RN, MAN

Anatomy & Physiology

Female Reproductive System

▪ External Genitalia – refers to the externally visible structure of the female

reproductive system extending from symphysis pubis to the perineum.

collectively called VULVA (pudenda)

a. Mons Pubis (mons veneris) -- fatty pad over the symphysis pubis; cushions & protects
pubic bone

b. Labia Majora (labium majus) -- longitudinal folds of pigmented skin extending from
mons pubis to the perineum; covered with thick, curly hair [Escutcheon]
c. Labia Minora -- hairless folds of tissue within the labia majora, extending from clitoris to
the fourchette
d. Clitoris – small (approx. 1-2 cm) rounded organ of erectile tissue at the upper end of
labia minora
Glans – tip of the Clitoral Body
Clitoral Body -
Prepuce - hood like covering
Smegma - epidermal secretion with strong odor
e. Vestibule – almond-shape space between the labia minora, clitoris and fourchette
contains structures:
a. Urethral meatus/orifice
*Skene’s glands (paraurethral glands)
b. Vaginal introitus
*Bartholin’s glands (vulvovaginal glands)
c. Hymen – crescent-shaped membrane
*Carunculae Hymenales

f. Fourchette -- thin fold of tissue formed where labia minora meets

g. Perineum – skin-colored muscular area between the vaginal orifice and the anus;
*Episiotomy site

▪ Internal Genitalia
Vagina – organ of copulation/ “Birth canal”
-Hollow, musculomembranous canal (8-12 cm) 4cm diameter
Fornix - anterior, posterior and lateral
space surrounding the cervix

Doderlein’s bacilli - keep vagina acidic

Functions of Vagina:
1. organ of copulation
2. Passage in delivery & menstrual blood
3. Secretory duct during menstruation

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 b. Uterus -- “the womb”
- pear-shaped, hollow muscular organ - anteverted, directed forward; 7-8 cm long
- functions:
o Menstruation
o Environment for pregnancy
o Labor & delivery

- Layers:
o Perimetrium - Outermost
o Myometrium -- middle layer
- “living ligature”
- layers of smooth muscle fibers that
interlaces=contraction
O Endometrium – innermost
- rich in gland and blood vessels
- sloughs off as menstruation

Parts of Uterus:
a. Corpus – main contractile portion
-- forms bulk
-- uppermost part (FUNDUS)

b. Isthmus - joins the corpus to the cervix

-- during pregnancy called: LUS
-- contains uterine canal

c. Cervix - forms the main opening of the uterus

-- 2-4 cm long
* Operculum
o internal os -- opens into uterine cavity
o cervical os
o external os -- opens into vagina

Uterine Ligaments:
– Broad = 2 winglike structures that extends from the lateral margin to the uterus
to the pelvic walls
– Round = 2 fibrous cords from the uterine walls that helps hold the uterus in its
forward position
– Utero-sacral/posterior = 2 cord-like folds of the peritoneum from the lower
cervix to the sacrum

Fallopian Tubes/Oviducts “Salpinges”

– serves as a passageway for the expelled ovum
– 10-12 cm long
Parts:
o Interstitial - part of tube that lies in the uterine wall
o Isthmus - part that is cut or sealed during tubal ligation
- attach tube to uterus
o Ampulla –
o Infundibulum - most distal portion

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 - its funnel-shaped opening encircled with FIMBRIAE * finger-like
projections which anchor ovary to fallopian tube

Ovaries – female gonads

- the sex glands sized and shape like almonds

functions:
1. Ovulation
2. Secretion of hormones
• Estrogen
• Progesterone

▪ Accessory Structures

a. PELVIS – passageway of fetus

Consists of
o two Innominate bone
- ilium (crest of ilium)
- ischium (ischial tuberosity)
- pubis
o sacrum
o coccyx
Pelvic Sections/Divisions:

False Pelvis -- larger, shallow

- lies above the inlet
- Aids in supporting abdominal viscera

True Pelvis -- low, deep

- pelvic inlet – entrance to the true pelvis
- midpelvis – mid portion of pelvis
*Contains ischial spine
- pelvic outlet – exit of the pelvis
*Linea Terminalis
Pelvic Measurements:
o Diagonal conjugate -- anterior sacral promontory to the inferior margin
of symphysis pubis (12.5 – 13cm)
o True conjugate -- Conjugate Vera - from anterior sacral promontory to
the SUPERIOR margin of symphysis pubis (11 – 11.5cm)
o Obstetric Conjugate -- Sacral promontory to INNER SURFACE of
symphysis pubis (10.5 - 11 cm)
o Biischial diameter -- distance between ischial spines (10 cm)
o Tuberischial diameter -- transverse diameter of outlet (8 cm)

BREASTS – Parts:
o Acini cells -- milk-producing cells
o Lactiferous sinus – storage
o Lactiferous duct/Collecting duct
o Nipples
o Areola – Montgomery’s tubercles

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 Hormones:

o Prolactin - hormone for milk ______________

o o Oxytocin - hormone for milk ______________

Male Reproductive System

▪ External Genitalia

a. Mons pubis – area over symphysis pubis

b. Penis – organ of urination & copulation

Shaft - corpus spongiosum
- corpus cavernosa
Glans penis - distal end of organ
Prepuce - protects glans at birth
c. Scrotum
- wrinkled pouch of thin skin, covering a tight muscle
- protects the testes from trauma and changes in temperature
- Cremasteric reflex

▪ Internal genitalia

a. Testes - male sex glands or gonads

- 2-3 cm wide that lie in the scrotum
Parts:
o Semineferous tubules - site of spermatogenesis
o Leydig’s / interstitial cells - secretes testosterone
o Sertoli cells - provide nourishment to the sperm

b. Epididymis-- storage site for maturing sperm - approx 20 ft. Long

c. Vas deferens - passage way for sperm from epididymis to seminal vesicles - *
Vasectomy
d. Ejaculatory duct - allows the sperm to enter the urethra and then exit the body
- passes the prostate gland

e. Accessory structures
o Seminal vesicles - located along the lower posterior surface of the bladder
- 30% semen produced
o Prostate gland - surrounds the prostatic urethra - 60% semen produced
o Bulbourethral gland/Cowper gland - located below the prostate - 5%
semen production

▪ Seminal Fluid
1. Nourishes the sperm
2. Protects the sperm from acidic environment of the vagina
3. Enhance motility of the sperm
4. Washes the sperm out of the urethra

▪ Semen-
- thick, whitish fluid ejaculated by the man during orgasm

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 - alkaline
Normal amt of sperm per ejaculation: 3-5 cc/ejac
Normal # of sperm/ejac: 120-150M/cc
Normal Life span: 7 days

f. Urethra - passageway for urine and semen - 18-20 cm hollow tube

Sexual Response Pattern ( 4-phase response by:

Masters & Johnson)
• Process:

 VASOCONGESTION

 MYOTONIA

1. EXCITEMENT
– 1st phase
-- “ foreplay” –
women:
- vaginal lubrication
- vaginal barrel lengthens & distends
- cervix & fundus are pulled upward
- clitoris increase in size –
men:
- erection
- scrotal skin becomes congested & thick
- (both) there is an increase in HR, RR & BP

2. PLATEAU
– 2nd stage
-- “the entry & coitus phase”
women:
- clitoris retracts under the hood
- vagina becomes greatly engorged along with labia minora forming
“orgasmic platform”
men:
- pre-orgasmic emission
- testes continue to elevate until they are situated close to the body to
facilitate ejaculatory pressure

3. ORGASM
– 3rd stage
-- “climax”
- strong vaginal contractions
- occurrence of ejaculation
- shortest stage of sexual response cycle
4. RESOLUTION
4th stage
- “phase of relaxation”
- the reproductive organs return to their unstimulated state

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 - REFRACTORY PERIOD

FEMALE REPRODUCTIVE CYCLE

A. Hormones
1. Follicle stimulating hormone (FSH)
- initiates the maturation of ovarian follicle
- Produced by APG

2. Luteinizing hormone (LH)

- responsible for ovulation
- forms the corpus luteum
3. Estrogen
- assists in maturation of ovarian follicle
- stimulates the thickening endometrium
- FSH suppression
- responsible for secondary sex characteristics
- stimulates contraction of smooth muscles

4. Progesterone
- increase body temp.
- Causes cervical secretions to be thick & viscous
- prepares endometrium to receive & nourish fertilized ovum
- relaxation of smooth muscles
- maintains pregnancy
B. Sources
1. Hypothalamus
- produces 2 hormones:
a. FSH-releasing factor (FSH-RH)
b. LH-releasing factor (LH-RH)
2. Pituitary gland
- produces FSH & LH
3. Ovaries
▪ Estrogen
▪ Progesterone

Menstruation
- Periodic shedding of blood, mucus & epithelial cells from uterus
- Generally, occurs 14 days after ovulation
- Ave. blood loss = 30-50 ml

Menstrual Cycle
- Time between the beginning of one period & beginning of next period
- Purpose: bring ovum to maturity & renew uterine tissue bed responsible for its growth

• Characteristics of Menstrual Cycle:

Ave. length – 28 days
Ave. flow – 3 to 5/ 5 to 7 days
Normal color – Dark red

Menarche– first menstrual period

Menopause– marks end of reproductive life as a result of estrogen depletion

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 Climacteric – transitional period during which ovarian fxn & hormonal prodxn decline (35 y/o)

ENDOMETRIAL CYCLE

MENSTRUAL PROLIFERATIV SECRETORY ISCHEMIC

(1-3) E (4-14) (15-24) (24-28)

↓ Estro & Proges Hypo: FSH-RF Formation of CL • Degeneration of CL

APG: FSH Fertilization: After 8-10 days if no
-stim FSH prodxn Ovary -- ↑ estro -- sex + sperm fertilization
-endometrium degenerates > Inhibit FSH ↑ proges
↓ estro & proges
=Menstruation Hypo: LH-RF APG: LH = Amenorrhea
Ovary--↑Proges Endometrium sloughs
• No Fert: off
= Ovulation -- no sex + no sperm
↓ proges

= PMS

OVARIAN CYCLE

Follicular Phase (Day 1-14)

1. ovarian follicles mature under the influence of FSH & estrogen
2. LH surge causes ovulation

Day 15-28 Luteal Phase

1. ovum is discharged from mature follicle
2. corpus luteum (“yellow body”) develops under the influence of LH
3. progesterone level increases
4. a> NO FERTILIZATION – corpus luteum atrophies 10 days after ovulation
5. b> WITH FERTLIZATION – conceptus produces HCG that sustains life of
corpus luteum

OVULATION
- rupture of graafian follicle & formation of the ovum
- occurs 14 days before the onset of menstruation
28 day cycle ---- 14th day
20 day cycle ---- 6th day
45 day cycle ---- 31st day

a. MITTELSCHMERZ
- abdominal pain associated with ovulation from release of prostaglandin

b. SPINNBARKEIT
- the ability of the mucus (cervical) to be stretched between 2 fingers about
1215 cm without breaking
- (+) ovulation: thin, watery, copious, slippery
- ferning pattern (using microscope)

c. BASAL BODY TEMPERATURE

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 - drops a day before ovulation followed by an abrupt rise after ovulation (0.5-
1˚F)
- get temp before rising early AM (at least slept 8 hours prior)

FAMILY PLANNING

• Natural or Fertility Awareness Methods

– consist of plotting or identifying particular days during each menstrual cycle when coitus
should be abstained on fertile period
– no protection from STDs

• Calendar/Rhythm Method
-- abstinence during fertile periods
-- 1-year menstrual cycle: subtract 18 days from shortest cycle and 11 days from longest
cycle
* Adv: inexpensive, convenient, no side effects, encourages communication
* Disadv: requires long period of abstinence & self-control; Regular mens
• Coitus Interruptus
-- withdrawal of penis from vagina before ejaculation
-- least effective method – sperm exist in pre-ejaculatory fluid
* Adv: inexpensive, medically safe
* Disadv: unreliable, interrupts sexual excitation Not eliminate risk of STD

Condom

Female: long polyurethane sheath inserted in vagina with ring at each end; 1 cover cervix & 1
covers labia
-- lubricated w/spermicide; inserted up to 8hrs before coitus
* Disadv: aesthetically unappealing, expensive for frequent use
- May cause allergy

Male: latex sheath that covers penis & prevents sperm from entering the vagina
-- 80% effective
* Adv: prevent conception & transmission of STD
-Available OTC; easily carried
-Helps maintain erection longer; prevents premature ejaculation
* Disadv: decrease spontaneity & sensation Should be used with vaginal jelly if condom/vagina
dry; CI in latex allergy

• Cervical Cap
-- small rubber or plastic dome that fits snugly over the cervix
-- provides protection up to 48h
• Half fill cap with spermicides
• Cap should be inserted 30 minutes before coitus
• Left in place for 1-2 days
• Removal: wash with warm water and mild unscented soap
Replace every 2 years
Refitted after pregnancy

• Diaphragm
-- mechanical device that fits over cervix & prevents sperm from entering cervical os -- used
w/spermicide
-- left in place 6 hrs after coitus

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 • Intrauterine Device (IUD)
-- device inserted into uterine cavity preventing fertilization or implantation
-- copper IUD: damages sperm & few reach the ovum
-- proges IUD: affects cervical mucus & endometrial maturation
-- A/E: increased menstrual flow, uterine infection, ectopic pregnancy, spontaneous expulsion of
device

• Oral Contraceptive
-- combined estro-proges oral preparation
-- 97% effective
-- prevent conception by inhibiting ovulation
Inhibits hypo, pit hormone prodxn
-- cause atrophic changes in endometrial lining to prevent implantation
-- cause thickening of cervical mucus to inhibit sperm travel
CI: smoking, cardiac disease, diabetes, older than 35 yrs old
-- S/E: thrombus formation, edema, weight gain, irritability, missed periods, n/v
* Adv: most reliable, may alleviate PMS symptoms, dysmenorrhea
Protect against ovarian & endometrial cancer
* taken Once, same time daily
• Minipills
-- low dose progesterone given alone
--use will result in a thin atrophic endometrium
* Adv: fewer s/e; can be used by lactating mothers; No estrogen s/e
* Disadv: irregular bleeding, increased risk for ectopic pregnancy
Major S/E:
• Thrombophlebitis
• Hypertension
• Libido changes
• Hyperglycemia
• CNS disturbances

• Transdermal contraception
– refers to patches that slowly but continuously release a combination of estrogen and
progesterone
– Patches are applied each week for 3 weeks

Areas to apply:
1. Upper outer arm
2. Upper torso (front or back excluding breast)
3. Abdomen
4. Buttocks

• Subdermal implants
– placement of 6, soft, flexible capsules filled with progesterone
Under the skin of the upper arm 8-10 cm above elbow
– Norplant System (levonorgestrel)
* Adv: long-acting (effective up to 5 yrs)

• Subcutaneous Injections
-- Medroxyprogesterone ( DMPA or Depo-Provera )
- injectable progestin: deep IM into gluteal or deltoid q3 mos.
-- S/E: spotting, headache, weight gain; Amenorrhea

Sterilization:

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 • Vasectomy
-- surgical ligation of vas deferens terminating sperm passage -- 99.5% effective; performed
outpatient basis
Nsg. Int:
• Signed consent
• Resume sex after 1 wk with 2 negative sperm
( after 10-20 ejaculations)
• Explain does not interfere with sperm prodxn, can still achieved full erection, ejaculation
of seminal fluid with no sperm
• Mild analgesics & ice pack for pain

• Tubal Ligation

-- fallopian tubes surgically ligated or cauterized through laparoscopy or minilaparotomy

--prevents impregnation of ovum by sperm
- done after menstruation or before ovulation
- provides immediate contraception
Nsg. Int:
• resume sex after 2-3 days
• does not affect menstrual cycle
• may be performed postpartum

MENSTRUAL DISORDERS

1. DYSMENORRHEA - painful menstruation

Types:
a. Primary – no demonstrable pathology
Mgt:

b. Secondary -- Pain with an underlying pathology

- uterine myomas, PID, endometriosis
Mgt:

• Mild:
• Moderate:
• Severe:

> Manifestation:
- “bloated feeling”
- light cramping 24h before mens
- colicky pain
- mild diarrhea
- mild breast tenderness
- nausea & vomiting
- headache

2. PMS (Pre- Menstrual Syndrome)

- cause: unknown, but may be due to the drop in progesterone just before menses
S/S:
a.

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 b.
c.
d.
e.
f.

Nursing Care:
a. restrict foods with methylxanthines, fat, salt sugar
b. complex CHO’s, CHON
c. increase frequency of meals
d. Vit. B & Vit. E supplement
e. Regular exercise
f. Meds
- pain
- edema –
- breast tenderness –
3. AMENORRHEA

a. Primary
-
-
b. Secondary
-
-

Mgt: ovulatory drug:

4. MENORRHAGIA

5. METRRORHAGIA
-
-

• Bleeding
o Perineal pad count
o Monitor V/S
H

IN

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FE
RT
ILI
TY
-

o Pri
mar
y
infe
rtili
ty –

o Sec
ond
ary
infe
rtili
ty –
Therapeutic Management:
1. Education about menstrual cycle & sexual therapy 2. Medications:
• Clomiphene citrate (Clomid)
-- ovulatory stimulant
-- follicle-maturing agent used during the fifth to tenth day of the
menstrual cycle
-- S/E:
• (Pergonal) human menopausal gonadotropin
-- acts similarly to FSH or LH to stimulate growth & maturation of ovarian follicle
• Bromocriptine (Parlodel)
-- inhibits release of prolactin

Medical Intervention

• Artificial Insemination
--

• In vitro fertilization
--

• Gamete intrafallopian transfer ( GIFT )

--

• Zygote intrafallopian transfer ( ZIFT )

--

• Surrogate mothering
--
--

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 FERTILIZATION / IMPLANTATION

I. Prefertilization

capacitation –

acrosome reaction
HYALURONIDASE –
❖ zona pellucida –
❖ corona radiata –

II. Conception / Fertilization

a. zona reaction
b. fertilization
-
life span of ovum – life span of sperm –
Sex determination:
>ovum – 23 chromosomes:
>sperm – 23 chromosome:
- zygote – fertilized ovum to implantation
- single cell, the product of fertilization

III. Implantation
a. Blastomere
b. Morula
c. Blastocyst
1. Trophoblast – outer portion 2. Embryoblast – inner portion
d. Implants -- 7 to 10 days after fertilization

A. EMBRYONIC MEMBRANES
1. Chorion -- outer membrane
2. Amnion -- inner membrane

• Deciduas
a. decidua basalis
− forms the maternal side of the placenta
− underlies the embryo
b. decidua capsularis
− overlies the embryo
c. decidua parietalis/vera
− lies the rest of the uterine cavity
− does not come in contact with the fetus
GERM LAYERS
• Ectoderm – amniotic cavity
• Entoderm – yolk sac -- supplies nourishment only until implantation; * provide source of
RBC
• Mesoderm
➢ 8 wks gestation= all organ system complete

Ectoderm Mesoderm Entoderm

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B. AMNIOTIC FLUID
- slightly yellow and transparent
- derived from fetal urine and fluid from mother - ave. amt:
- pH: 7.2 slightly alkaline

OLIGOHYDRAMNIOS =

POLYHYDRAMNIOS/HYDRAMNIOS =

Functions:
1. Cushion the fetus
2. Maintain even temperature
3. Provide source of oral intake for the fetus
4. Protects umbilical cord from pressure
5. Allows the fetus to move freely

C. PLACENTA
- “pancake”
- develops at the 3rd week of gestation; 2 Functions:
1. Metabolic function
- produces nutrients needed by the embryo
- synthesis of glycogen, cholesterol & fatty acids

2. Endocrine function
- secretes 4 hormones:
1. Human Chorionic Gonadotropin (HCG)

2. Human Placental Lactogen (HPL)

- also called _______________________________
- promotes normal nutrition & growth of the fetus
- promotes maternal breast dev’t for lactation

3. Estrogen --

4. Progesterone --

2 Components of the Placenta:

1. Maternal -- rough/dirty where it attaches to uterus
2. Fetal side -- smooth & shiny

D. UMBILICAL CORD

a. 2 arteries

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 b. 1 vein

c. wharton’s jelly
-

FETAL DEVELOPMENT
1. Circulatory System
3rd week – heart beats
4th–5th week – heart’s chamber develop
2. Respiratory System
11th week – respiratory movement
24th week – surfactant production
3. Renal System
5th week – kidney function 12th week – urine formation full term - fully develop kidney
4. Neuromuscular System
11th-12th week – fetal movement
20th week – distinguishes taste
24th week – responds to sounds 28th week – opens eyes
full term – brain is ¼ the size of an adult’s brain
5. Gastrointestinal System
9th week – synthesizes glycogen
16th week – formation of meconium
6. Endocrine System
3rd-4th week – formation of thyroid gland
8 week – secretes thyroxin
th

12th week – pancreas produces insulin

7. Reproductive System
8th week – genital appears
12th week – sex differentiation
8. Musculoskeletal System
6th week – development of bones
7th week – contraction of muscles
9. Integumentary System
12th week – lanugo appears
16th week – hand & footprints appear
20th week – vernix caseosa appears
28th week – lanugo thins
32nd week – subcutaneous fats thickens
10. Immune System
24th week – IgG cross placenta passive immunity until 2 mos.

PREGNANCY
Gravida -
Para -
Duration of Pregnancy

CONFIRMATION OF PREGNANCY
A. Presumptive Signs

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 1. amenorrhea
- impregnation has occurred
- stress
- anemia
- strenuous exercise
2. nausea & vomiting
- increase HCG level
- GI disorder
- Emotional stress
3. frequent urination
- pressure of the uterus to the bladder
- UTI
4. fatigue
- fetus is using the mother’s glucose rapidly
- illness
- overexertion
5. quickening
-
Primigravida: ____ weeks
Multigravida: ____ weeks
- presence of gas in intestine may also stimulate same sensation
6. pigmentations – 24th week - chloasma
- Striae gravidarum
- Linea nigra
7. breast changes
- usually noticeable during 1st pregnancy

B. Probable Signs
- objective signs
- signs that can be documented by the examiner
- still, they are not foolproof
1. abdominal enlargement
2. ballottement
-
3. Hegar’s sign
-
4. Chadwick’s sign
-
- -
5. Goodell’s sign

6. Braxton Hicks’s contraction

7. positive pregnancy test

-
8. Ladin’s sign
- presence of a soft spot in the middle of the uterus
9. Braun Von Fernwald’s sign
- irregular enlargement @ the site of implantation
10. Piskacek’s sign
- tumor like enlargement of the uterus

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C. Positive Signs
1. Auscultation of fetal heart sounds
- 18th-20th weeks gestation by ____________
- 10th-12th weeks by _______________
2. Fetal movements felt by the examiner

3. Visualization of embryo or fetus

- ultrasound confirms pregnancy as early as 5-6 weeks gestation by the
presence of gestational sac

PHYSIOLOGIC CHANGES OF PREGNANCY

1. Breasts
- increase in size & nodularity
- enlarged Montgomery’s tubercles
- veins become prominent
- precolostrums can be expressed from nipples as early as 12 th-14th weeks
2. Uterus
- increase in vascularity
- presence Hegar’s sign
3. Cervix
- formation of mucus plug or operculum
- presence of Goodell’s sign
4. Vagina
- Chadwick’s sign
– Leukorrhea
5. Cardiovascular System
- increase in blood volume
- increase in cardiac output
- varicosities
- supine hypotension
6. Respiratory System
- increase O2 demand
- increase chest circumference
- displacement of the diaphragm
7. Gastrointestinal System
- swollen gums (“epulis of pregnancy”)
- constipation - heartburn
- hemorrhoids
8. Urinary System
- urinary stasis
- urinary frequency
9. Musculoskeletal System
- lordosis (pride of pregnancy)
- characteristics waddle
- diastasis recti
10. Integumentary System
- chloasma/melasma
- linea negra
- striae gravidarum
11. Endocrine System
- increase activity & hormone production

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 - slight hyperparathyroidism
- enlargement of the thyroid gland
- increase melanocyte stimulating hormone

PSYCHOLOGIC CHANGES OF PREGNANCY

-PREGNANCY: Maturational Crisis

1. First Trimester
- ambivalence
- fear
- fantasies about motherhood & about having a “dreamchild”
- possible decrease in sex drive TASK:

2. Second Trimester
- alternate feelings of emotional well-being & liability
- acceptance of pregnancy
- possible increase in sex drive
- adjustment to change in body image TASK:
3. Third Trimester
- feelings of awkwardness & clumsiness
- renewed fears & tension about labor
- spurt of energy during the last month “Nesting Instincts” TASK:

COUVADE SYNDROME

ANTEPARTUM ASSESSMENT & CARE

1. Frequency of visit
1-7 months: every month
8 months: every 2 weeks
9 months: every week

2. Estimates
a. EDD / EDC
• Naegel’s Rule
- 1st day of LMP
- subtract 3 months
- add 7 days
- change the year

b. Fetal length
• Haase’s Rule
- 1 to 5 months (multiply the age of pregnancy by itself)
Ex: 4 months x 4 = 16 cm

- 6 to 9 months (multiply by 5)

• Mc Donald’s Rule

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 - lunar months
fundal height(cm) x 2/7 Ex: 14 cm x 2/7 = 4 months
- Weeks: fundal height (cm)x8/7=16 weeks
Ex: 14 cm x 8/7 = 16 weeks

3. Assessment
a. Demographic Data
-address, telephone number, race/ethnic group, religion, health insurance b. Family
profile
- identify support system, size of house, her age & partner’s age, educational levels,
occupation
c. Family history
- Inherited disease
- Congenital Anomalies
d. Past medical history
- Cardiac, kidney, STD’s, DM, Thyroid, Respiratory, Surgical procedures, Injuries,
Childhood Diseases, Allergies/ drug sensitivities
e. Social profile
• Information of woman’s lifestyle:
– Exercise
– Hobbies
– Smoking
– Drinking habits
– Medication history; Recreational drugs
f. Gynecologic history
a. Reproductive tract
b. Breast problem
c. Menarche
d. Menstrual cycle (interval, duration, amount, discomfort)
e. Past surgery on reproductive tract
f. Reproductive planning method
g. Sexual history
g. Obstetric history
G - # of pregnancies
T – term pregnancy
P – preterm pregnancy
A – abortion
L – living children
M – multiple pregnancies
Physical Examination
- vital signs
- height & weight
- pelvic measurement
- abdomen
Fundal Heights:
Fundus @ the symphysis pubis – 12 weeks
Fundus @ the umbilicus – 20 weeks
Fundus @ 28 cm from top of symphysis pubis – 28 weeks
Fundus @ lower border of rib cage (xiphoid process)– 36 weeks

Laboratory tests:
1. Blood grouping = to determine the blood type
2. Hgb/Hct = to detect anemia

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 - Hgb < 11 g/dl or Hct < 32% requires iron supplementation
3. CBC = to detect infection or cell abnormalities
- increase or 15,000 more or decrease requires follow up
4. Rh factor = for possible maternal-fetal blood incompatibility
5. VDRL = serologic test for syphilis
6. Urinalysis = test for albuminuria, glucosuria, pyuria

Leopold’s Maneuver

Preparation:
1.
2. Pos’n:

Steps:
1. Palpate what is lying in the fundus. BREECH – round, hard, mobile
CEPHALIC – irregular, soft, non-mobile

2. Palpate fetal back in relation to the right & the left.

3. Locate presenting part @ pelvic inlet & check for engagement.
4. Palpate just above the inguinal the relationship of the presenting part to the pelvis.
Assessing the Fetal Heart Tones

Fetal Heart Tones

-
- Normal:

1. Uterine Bruit/ Souffle

2. Funic Souffle

VARIATIONS IN FETAL HEART BEAT

1. Early deceleration
-
Mgt:
2. Late Deceleration

Mgt:

3. Variable deceleration
-
Mgt:

ASSESSMENT OF FETAL MATURITY & WELL BEING -

done during the 26th week of gestation

I – AMNIOCENTESIS
➢ removal of amniotic fluid from the uterine cavity

20
 ➢ early 1st trimester –
➢ 3rd trimester –

Preparations:

a. Lecithin/Spingomyelin (L/S) Ratio

- measures maturity of fetal lung
- the protein component of the enzyme surfactant - Normal Ratio:

b. Alpha-Feto Protein
- major plasma of early fetus
- decrease after 13 weeks of gestation - with AFP:

POST AMNIOCENTESIS:
a.

II – NON STRESS TEST (NST)

Indications:
a.
b.
c.
Procedure:
• woman is placed in semi fowlers position
• external fetal monitor is attached to the abdomen
• fetal heart beat & fetal movement are recorded on the same strip of paper

Interpretation:
REACTIVE:

NON-REACTIVE:

III – OXYTOCIN CHALLENGE TEST (OCT) / CONTRACTIONS STRESS TEST

(CST)
- done for evaluation of the ability of the fetus to withstand the stress of
uterine contractions

Indication:
➢

Procedure:
➢

Interpretation:
➢ Negative:
* No Late Deceleration ➢ Positive:
* Indicates Placental Insufficency

21
 HEALTH EDUCATION

1. Weight gain
Normal weight
2-5 lbs – 1st trimester
1 lb/week – 2nd & 3rd trimester
Total Weight Gain: 25-35 lbs

2. Nutrition
Calories – increase 300 K cal/day
CHON – 4 servings of meat recommended or 60 g/day
Ca – 1200 mg/day
Folate – 400 ug/day
Iron – 30 mg/day
3. Rest
- encourage mother to sit down & elevate the feet
- 10 hours of sleep
4. Exercise
- amount & type of exercise depend on the physical condition of the woman &
stage of pregnancy

a. Walking –
b. Kegels exercise –
c. Tailor sitting – for relief of backache
d. Pelvic tilt – for relief of backache
e. Shoulder circling – for relief of backache

5. Sexual Relations
-- no restrictions
-- CI:
- strong uterine contraction after orgasm

Common Discomforts of Pregnancy

a. nausea & vomiting Mgt:

b. heartburn
Mgt: eat small, several meals
− avoid smoking & coffee (cause hyperacidity)
− sit upright especially after meals
c. constipation
Mgt: drink @ least 8 glasses of H20 a day
− increase fiber in diet
− exercise
d. Varicosities
Mgt: avoid constricting clothing
- avoid crossing legs at the knees
- take frequent rest periods with legs elevated
- wear support hose or elastic stockings

22
 e. hemorrhoids
Mgt: hot sitz bath
-- apply cool witch hazel compound
-- knee chest
f. leg cramps
Mgt:
g. frequent urination
Mgt: will be resolved without intervention. However, you can use Kegel’s
exercise to lessen the discomfort
h. backache
Mgt:
- tailor sitting
- shoulder circling
- pelvic rock
- squat rather than bend when lifting
i. Leukorrhea
Mgt:

j. Hypotension
Mgt: L side lying position
k. Dyspnea
Mgt: elevate head of bed
l. Ankle edema - reduced blood circulation in lower extremities Mgt:
- avoid constricting clothing
Pica
-

DANGER SIGNS OF PREGNANCY

a. vaginal spotting/bleeding
b. leaking of fluid from the vagina
c. unusual abdominal cramps
-- ectopic pregnancy in 1st trimester & abruptio placenta in 3rd trimester d. persistent
headache, blurring of vision
a. marked swelling of hands & feet
b. painful, burning urination discharge
c. foul smelling vaginal discharge
d. chills & fever
e. persistent nausea & vomiting

LABOR & DELIVERY

A. Theories
1. Uterine Stretch
- as the uterus becomes stretched, pressure increases & physiologic changes
occurs

2. Oxytocin
- as pregnancy progresses, uterus becomes more sensitive to oxytocin

23
 3. Progesterone deprivation
- decrease level of progesterone results to smooth muscle contraction

4. Prostaglandin cascade
- there is an increase level of prostaglandin during the late month of
pregnancy
- results to uterine contraction

B. Mechanics
1. Passage
a. Gynecoid -- normal female pelvis
- ideal for childbirth
- round shape pelvic inlet
b. Android -- male pelvis
- heart shaped pelvic inlet
c. Anthropoid -- “ape like” pelvis
- oval shaped pelvic inlet
d. Platypelloid -- flattened pelvis
- reverse oval shaped
2. Passenger
• Fetal bones
- 2 frontal bones
- 2 parietal bones
- occipital bone
• Suture lines
- strong but flexible tissue that connects 5 major bones
--coronal suture
--saguittal suture
--lambdoidal suture
--frontal suture

• Fontanels
- anterior fontanel – diamond shape posterior fontanel – inverted
triangle

• Head measurements
1. Biparietal diameter
- measurement from 1 parietal prominence to another
- 9.25 cm

2. Suboccipitobregmatic diameter
- measures from the undersurface of the occiput to the center of the
anterior fontanel
- 9.5 cm

3. Occipitofrontal diameter
- measures from posterior fontanel to the bridge of the nose - 11/11.75
cm
4. Occipitomental diameter
- measures from the occipital bone to the chin/mentum
– 13.5 cm

24
• Fetal lie
-
--transverse
--longitudinal

• Fetal attitude
-
--good flexion
--moderate flexion
--poor flexion

• Fetal presentation

• Cephalic
-
Reasons:

a. fetal head is the largest single fetal part, after it is born, the smaller
parts follow easily
b. fetal head can gradually change shape, molding to adapt to the size
& shape of the maternal pelvis
c. fetal head is smooth, round & hard, making it more effective part to
dilate the cervix

Types of Cephalic Presentation

a. Vertex
- most common
- fetal head fully flexed
- suboccipitobregmatic diameter is presenting b.
Military
- fetal head is in neutral position
- neither flexed nor extended
- occipitofrontal diameter is presenting
c. Brow
- fetal head is partly extended
- unstable
d. Face
- poor flexion
- complete extension of all body parts

Breech (Buttocks)

Disadvantages:
- less effective in dilating cervix
- fetal head is the last part to come out

3 Variations:
a. Frank Breech
--most common
--hips are flexed but the knees are extended to rest on the chest
--the buttocks alone present to the cervix

25
 b. Complete breech
--the fetus has thighs tightly flexed on the abdomen
--both the buttocks & the tightly flexed feet present to the cervix c.
Footling
--one foot presents: Single Footling
--if both present: Double Footling

Shoulder/Transverse Presentation
-the shoulders is in transverse lie

• Fetal station
= the relationship of the presenting part to the level of the ischial parts
-4
-3 floating: 3cm above
-2 floating: 2cm above -1 floating: 1 cm above 0 ischial spine:
+1: 1cm below the ischial spine
+2 2cm below the ischial spine
+3 3cm below the ischial spine
+4

• Fetal Position
= relationship of fetal presenting parts to the mother’s pelvic quadrants
• Nomenclature
– Position/Presentation/Variety
– 3 Letters
1st letter: landmark pointing to mother’s [ R or L ]
2nd letter: fetal landmark [ O, M, Sa, A ] 3rd letter: landmark points [ A, P,
T ].

3. POWER
A. Phases
1. Increment
2. Acme/Peak
3. Decrement

B. Assessment
1. Frequency
-- from the beginning of 1 uterine contraction to the beginning of the next -- expressed in
minutes (3-4 mins)
2. Duration
-- length of each contraction from the beginning to end
-- express in seconds : 30 secs
3. Interval/ Relaxation
-- period between the end of 1 contraction & the beginning of the next
4. Intensity
-- strength of contractions
-- express in mild, moderate, strong

4.PSYCHE -- mental preparation of the mother for labor & delivery

-- marked anxiety or fear
-- relaxation

26
 PREPARATION FOR CHILDBIRTH

1. Dick - Read
- slow abdominal breathing in early labor & rapid chest breathing in advance labor
2. Bradley
- include the father as a support person for “husband-coached childbirth”
3. Le Boyer
- views birth as a traumatic experience fro the neonate
- lights are dimmed & noise is decreased during delivery to keep the newborn adapt to
extrauterine life more easily
4. Lamaze
- called “psychoprophylaxis”, because it uses the mind to prevent pain
- uses relaxation & breathing exercises, imagery or massage as pain relief measures -
support person: a husband or a coach
5. Kitzinger
- program of conscious relaxation & levels of progressive breathing
- uses sensory memory

SIGNS OF IMPENDING LABOR

1. Lightening
-
- effects:

2. Braxton-Hicks contraction
- becomes more noticeable & painful in the last month of pregnancy - strong frequent but
irregular uterine contractions

3. GI upset
- women frequently experience diarrhea, indigestion or nausea & vomiting few days
before labor

4. Burst of energy
- “nesting”, the pregnant woman is busy preparing the things of her baby

5. Blood Show

6. Ruptured BOW

TRUE LABOR VS. FALSE LABOR

TRUE FALSE
1. Contractions regular, become irregular, not
more intense
frequent, gradual
increase in duration
& intensity
2. Discomforts begins @ the lower primarily on the
back & radiates abdomen
around abdomen only

3. Effects of contractions are contractions may

intensified when decrease or

27
Walking walking disappear when
walking
4. Cervical progressive no cervical changes
changes dilatation &
effacement

CARDINAL MOVEMENTS
(Mechanisms of Labor)
A. Descent

B. Flexion
baby moves further downward & then head meets obstruction at the pelvic floor
causing flexion

C. Internal Rotation
For the head to pass the pelvic outlet
The head flexes as it touches the pelvic floor, & the occiput rotates until it is
suspended, or just below the symphysis pubis, bringing the head into the outlet of the
pelvis

D. Extension
occurs as the fetal head passes beneath the symphysis pubis.
After internal rotation, head of the baby extends with position still the same so that the
face & neck can come out

E. External Rotation
almost immediately after the infant’s head is born, the head rotates back into the
diagonal or transverse position to deliver the shoulders

F. Expulsion
once the shoulders are delivered, the rest of the baby is delivered easily & smoothly
because of its smaller size

STAGES OF LABOR

A. First Stage (Stage of Dilatation)

3 Phases:

1. Latent Phase
>
>
> Mgt:
1. encourage ambulation
2. check V/S, FHR, contraction
3. clear fluids or ice chips
4. left-side lying position
5. breathing techniques:

6. encourage voiding Q2H

28
 2. Active Phase
>
>
>
Mgt:
1. check V/S, FHR, contractions
2. calm environment
3. comfort measures
➢
➢
4. breathing techniques:
➢
5. IVF
6. provide psychosocial support
7. Analgesia – Meperidine HCl (Demerol) – IV or IM
-- admin during Active labor [ 4-7 cm ]
-- to allow metabolism & excretion of drug before birth to avoid respi
depression in newborn

3. Transition Phase
>
>
>
Mgt:
1. check V/S, FHR, contractions 2. be alert for bladder distention 3. I.E.
4. avoid pushing
5. provide short, concise information
6. breathing technique:
➢
7. nausea & vomiting may occur

B. Second Stage (Stage of Expulsion)

Mgt:
1. check V/S, FHR, contractions 2. I.E.
3. positioning
- lithotomy position with head elevated
4. perineal prep
5. breathing technique:
- 2 short breaths, hold 3rd breath while pushing
- never open mouth
6. catheterization
- may be done to avoid bladder distention because a full bladder impedes
the descent of the baby
7. episiotomy
Types:
➢ Median/Midline
➢ Mediolateral

Purposes:
a.to avoid laceration of the perineum

29
 b. to shorten the 2nd stage of labor
c. to avoid prolonged pressure on infant’s head
8. Hand Maneuver
a. Ritgen’s maneuver
➢ pressing forward on the chin of the fetal head while
pressing the other hand downward on the fetal occiput
b. palpate for cord coil
c. suction baby’s mouth & nose using a bulb syringe
d. deliver the shoulder, wait for the external rotation where 1
shoulder is up & the other shoulder is down
e. one hand @ the back of the neck, the other one grasping
the extremities & put the baby in the mother’s abdomen &
suction
9. Cord clamping & cutting
- milk the cord towards the baby
- cut the cord when it stops pulsating

C. Third Stage (Placental Stage) 1. Placental Separation

a. Calkin’s sign
b. gushing of blood
c. lengthening of the cord 2. Placental Expulsion
-- Brandt – Andrews Maneuver a. Shultz Mechanism
a. Duncan Mechanism
Mgt:

1. Medication
a. Oxytocin (Syntocinon)
- given IV after delivery of baby
b. Methylergonovine Maleate (Methergine)
- given IM after delivery of the placenta
Major S/E: Maternal
• Hypertension
• Dysrhythmias
• Hypertonic uterus
• Water intoxication

Nsg. Considerations:
1. Monitor client. Assess BP before admin
2. O2 & emergency resuscitative equipment at bedside
3. Use infusion pump, piggyback
4. Stop infusion if prolonged uterine contractions 5. -- lasting more
than 2mins, 70secs duration

2. Inspect the placenta

3. Episiorraphy

Perineal Lacerations:
• First Degree
--
• Second Degree
--
• Third Degree
--

30
• Fourth Degree
--
Initial Newborn Care

1. Establish & maintain patent airway

-- suction with bulb syringe mouth then nose

2. Evaluation of APGAR score

-- [1st min & 5 min ]
Purpose: assess adaptability to extrauterine life
Mgt: 7-10 – good
3-6 – moderately depressed ( admin O2 )
0-2 – severely depressed ( resuscitation )

3. Maintain body temperature

-- drying infant, radiant warmer
Evaporation –
Radiation –
Convection – Conduction –

4. Promote parent bonding

- en face position –

5. Assess for gross physical abnormalities Assess gestational age:

- AGA= weight between 10th & 19th percentile
- LGA = wt. above 19th percentile
- SGA = wt. below 10th percentile for age
- LBW = wt. 2500g or less

6. Identification of infant [ footprints ]

7. Eye care: prophylactic eye treatment

-- opthalmia neonatorum

- silver nitrate 1%
- erythromycin or tetracycline

8. Vitamin K administration
-- 0.5 to 1mg single IM vastus lateralis --to prevent hemorrhagic dse.

D. Fourth Stage (Stage of Physical Recovery)

Mgt:
1. Assess uterine contractility
- uterus must be firm & well contracted
- check for uterine involution
➢ 1 H after delivery: uterus @ the level of the umbilicus
➢ 1 day after delivery: uterus 1 fingerbreadth below umbilicus (1cm) ➢ 2nd-9th day
– 1 fingerbreadth a day ➢ 10th day – nonpalpable.

2. Assess for lochial discharge

a. Lochia rubra
b. Lochia serosa

31
 c. Lochia alba
3. Assess perineum for bleeding

4. Assess for level of pains

- “afterpains” – abdominal pain associated with uterine contractions

PUERPERIUM -- delivery – 6 to 7 weeks

1. Postpartal Bleeding
-- bleeding in excess of 500ml within 24hrs following birth
-- assoc with uterine atony, lacerations, retained placental fragments
Mgt:
- Monitor vital signs
– Uterine massage
– Insert Foley cath; MIO
– Admin oxytocin
– Monitor bleeding; perineal pad count

2. Breast care
-wash only with water
-air drying
-wear bra
Breastfeeding:
a. warm shower
b. express milk manually Bottlefeeding:
a. avoid handling the breasts
b. ice bag to breasts
c. analgesic for pain

▪ Breast Engorgement
-- occur at 3rd day
--attributed to milk “coming in”
--resolves within 48h
--hard, nodular breast

▪ Mastitis
--
-- occurs at
- CA:
Mgt:
– Frequent emptying of breast (q 2hrs)
– Apply warm compress
– Encourage to wear supportive bra
– Administer antibiotics as prescribed
– Comfort measures: small side pillow

3. Resumption of sex

4. Return of Menstruation

32
 - for breastfeeding mother: within
- bottlefeeds: within

PSYCHOSOCIAL ADAPTATION

1. Taking – in Phase
➢ happens 1st 3 days
➢ passive dependence
➢ time for reflection
➢ little interest in taking care of her child

2. Taking–hold Phase
➢ independence
➢ woman already shows interest in taking care of her baby

3. Letting-go Phase
➢ redefining new role

POSTPARTUM BLUES Onset:

Symptoms: sadness, fears
Incidence: 75% of all births
Etiology: probable hormonal changes, life changes
Therapy: support, empathy
Nursing Role: offer compassion & understanding

POSTPARTAL DEPRESSION Onset:

Symptoms: anxiety, feeling of loss, sadness
Incidence: 10% of all births
Etiology: history of poor parent relationship, hormonal response
Therapy: counseling
Nursing Role: refer for counseling

POSTPARTAL PSYCHOSIS Onset:

Symptoms: delusions, hallucinations
Incidence: 2% of all births
Etiology: activation of previous mental illness, hormonal changes
Therapy: psychotherapy, drug therapy
Nursing role: refer for counseling,
safeguard mother from injury to self or newborn

*COMPLICATIONS OF PREGNANCY*

BLEEDING DISORDERS OF THE 1ST TRIMESTER A.

Spontaneous Abortion

Classification:
1. Threatened Abortion
=

Mgt:
a.

33
 b.

2. Inevitable/Imminent Abortion Mgt:

a.
b. if no FHB –
c.
3. Complete Abortion
- -
Mgt:
a.
b.
4. Incomplete Abortion
-
-
Mgt:
a.
5. Missed Abortion

Mgt:
a.
b.
6. Habitual or Recurrent

Mgt: a.

B. Induced Abortion

Purposes:
a. preserve health of the mother
b. prevent the birth of an infant with severe gastric defects
c. end pregnancy caused by rape or incest
d. to terminate the pregnancy of woman who chooses not to have a child @
this time in her life

Types:
1. Therapeutic
=

2. Elective
=

Methods:
a. Vacuum aspiration or curettage - done up to 13 weeks of gestation
- cervix is dilated by metal rods then the Curette -- to ensure that it is empty
- cramping is expected _______________________

b. Dilatation & Evacuation

- done from 13 weeks to 16 weeks of gestation - cervix is dilated with: -
Laminaria - Prostaglandin Gel
c. Labor Induction
- done on 16th week up to 24thweek gestation

C. Ectopic Pregnancy

34
 Sites:
1. 2. 3.
4.
Causes:
1. narrowing of the tube
2. pelvic infection
3. endometriosis
4. smoking

Manifestations:
1. vaginal bleeding
2. knife-like abdominal pain
3. referred pain on the shoulder
4. symptoms of shock
5. pelvic pressure or fullness
6. pelvic mass
7. Cullen’s sign

Diagnosis:
1. 2.
3.

Mgt:
1. monitor amount of bleeding
2. monitor V/S
3. assess/observe for abdominal pain
4. blood transfusion
5. prepare for surgery
Salpingostomy
Salpingectomy
Oophorectomy
6. psychological/emotional care • DOC:
-- attacks & destroys fast-growing cells
-- folic acid antagonist

• Mifepristone
-- abortifacient
-- cause sloughing off of tubal implantation

BLEEDING DISORDERS OF THE 2ND TRIMESTER

1. Hydatidiform Mole (H mole)

Predisposing Factors:
a. low socio economic status
b. women below 18 or above 35 y.o.

35
 c. intake of Clomid
d. women of Asian heritage

Types:
1. Complete/Classic
2. Incomplete/Partial
Manifestations:
a. vaginal bleeding
b. excessive nausea & vomiting
c. rapid enlargement of uterus
d. (+) pregnancy test
e. abdominal cramps
f. absent FHR
g. elevated HCG titer: 1-2m IU Mgt:
a. D&C
b. Chemotherapy
c. Monitor HCG level
d. Delay childbearing for 1 year
e. Perineal pad count
f. Chest X-ray

2. Incompetent Cervix

Causes:
a.
b.

Risks:

Manifestations:
a. vaginal bleeding/show
b. painless dilatation
a. premature rupture of membranes

Mgt:
a.
b. medications:

c. surgery
*Cervical Cerclage
a. Shirodkar-Bartor
b. Mc Donald’s

BLEEDING DISORDERS IN THE 3RD TRIMESTER

A. Placenta Previa B. Abruptio Placenta

Predisposing Factors: Predisposing Factors:

36
 1. multiparity 1. chronic hypertensive disease
2. advanced maternal age 2. multigravida
3. alteration in uterine structure 3. history of short cord
4. trauma
5. inhalation of cocaine

Types: Types:
1. Low-lying or Marginal 1. Covert or Central
2. Partial/Incomplete 3. 2. Partial/Marginal
Total/Complete 3. Complete/Total

Complications:
1. Couvelaire Uterus
2. shock
3. DIC (Disseminated Intravascular
Coagulation)

Interventions:
1. bedrest in side lying position
2. Tocolysis
3. no IE/enema
4. IVF
5. adm O2 as ordered
6. perineal pad count
7. assess s/s of shock
8. monitor fetal status
9. psychological support

C. PREMATURE RUPTURE OF MEMBRANES (PROM)

Contributing Factors:
a. infection of the vagina
b. incompetent cervix
c. hydramnios
d. amniotic sac with weak structure
e. recent sexual intercourse

Complications:
1.
2.
3.

Dx:

Mgt:
a. Gestation Near Term
- induction

37
 - CS may be done

b. Preterm gestation
- complications of prematurity
- cervix is usually not favorable for induction
- CS may be done

Nsg. Intervention:
a. check FHR
b. check vaginally for prolapsed umbilical cord, or in case of advance labor for
descent of presenting part
c. check the color of amniotic fluid Normal: clear
Meconium Stained:
➢ Cephalic –
➢ Breech –

PREMATURE LABOR & BIRTH

Contributing Factors:
a. multiple gestation
b. polyhydramnios
c. premature rupture of membranes
d. incompetent cervix
e. placenta previa/abruptio placenta
f. previous preterm labor
Mgt:
a. Prevention of Premature Delivery
- if woman is currently in preterm labor, she is admitted to the hospital
➢ - induction may be done if labor does not begin spontaneously
- CS may be done
b. Patient Teaching
- teach woman symptoms of preterm labor
➢ uterine contractions in regular pattern for more
than 1 hour while @ rest
➢ intermittent or constant uterine cramps
➢ low, dull backache
➢ intestinal cramping
➢ rupture of membrane MULTIPLE
GESTATION
Types:
a. Monozygotic Twins
➢ _______________ twins”
--only same sex
--1 ovum, 1 sperm
--1 placenta, 1 chorion, 2 amnions, 2 umbilical cords

b. Dizygotic Twins
➢ “_______________ twins”
--2 ovum, 2 sperms
--2 placentas, 2 chorions, 2 amnions, 2 umbilical cords --same or
different sex Manifestations:
a. uterine size is greater than expected
b. palpation of three or more large parts

38
c. different FHT of different frequencies

Complications:
a. premature delivery
b. hemorrhage
c. HPN
d. Fetal malpresentation
e. Uterine dysfunction due to overstretching
f. Cord compression
g. Twin-to-twin transfusion syndrome

• Recipient Twin

• Donor twin

Mgt:
a.
b.
c.
d.

‫ ٭‬Rh INCOMPATIBILITY

1st Pregnancy
•no problem
• during delivery antigen-antibody reaction
•development of antibodies (sensitization) of the mother 2nd Pregnancy:
➢ ERYTHROBLASTOSIS FETALIS

Preventive Mgt:
a. Blood typing / Rh determination
b. Coomb’s test
➢ Indirect – mother’s blood
➢ Direct – umbilical cord sample
c. Rhogam
Curative Mgt:
1. Exchange Transfusion
− umbilical catheter is withdrawn, equal amount of Rh (-) donor blood is
transfused
− procedure is continued until most of the blood is replaced

2. Intrauterine Transfusion
a. 2 to 3 hours before the transfusion to begin, 50 ml of radiopaque dye is
injected into the amniotic fluid by amniocentesis technique
b. fetus will swallow the amniotic fluid with dye & will be present in the
intestine
c. with the aid of sonogram, cannula is inserted into the fetal abdomen &
blood O negative will be deposited into the abdomen

39
 d. the RBC will be absorbed across the fetal peritoneum into the circulation

COMPLICATIONS OF LABOR & DELIVERY A.

Dystocia

1. Powers

a. Hypertonic Labor Pattern occurrence:

characteristics:
➢ contractions that are frequent, strong but uncoordinated
➢ contractions that are ineffective in accomplishing cervical
effacement
& Dilatation Treatment:
➢
➢

b. Hypotonic Contractions occurrence:

characteristics:
➢ uterine contractions that are inadequate causes:
➢ early analgesia
➢ bladder or bladder distention
➢ multiple gestation
➢ large fetus
➢ hydramnios
➢ grandmultiparity
➢
Treatment:
➢
➢

2. Passageway –
➢ contracted uterus
➢ unfavorable pelvic shapes
Mgt:
b. evaluate pelvic diameters
c. continue labor with careful
monitoring
d. perform assisted vaginal or
caesarean delivery
3.
Psyche
➢ fear, anxiety & tension increase stress & can decrease uterine
contractility
➢ stress interferes client’s ability to work with her contractions
➢ stress increases fatigue

B. PRECIPITATE DELIVERY
-

Predisposing Factors:
➢ multiparity
➢ history of rapid labor
➢ premature or small fetus
➢ large bony pelvis

40
 Risks:

Mgt:
➢ fetal monitoring
➢ analgesia
➢ assess for birth injury
➢ assess for cervical vaginal & perineal lacerations

C. UMBILICAL CORD PROLAPSED

Causes:
1. breech presentation
2. transverse lie
3. unengaged presenting part
4. hydramnios
5. small fetus

S/Sx:
1. cord is protruding from vagina
2. cord can be palpated in the vagina or cervix
3. fetal distress

Mgt:

OBSTETRIC INTERVENTIONS

A. INDUCTION OF LABOR

Indications:
1. HPN, pre-eclampsia or eclampsia
2. prolonged ruptured of membrane
3. postmaturity
4. DM Prerequisites:
1. longitudinal lie
2. ripe cervix
3. engaged
4. no CPD – Danger Signs:
1. contractions occur more than q2min
2. contraction duration exceeds 75 – 90 seconds
3. uterine resting tone increase steadily, or uterine
relaxation between contractions is insufficient.

41
 B. FORCEP DELIVERY

Types:
1. Outlet/Low Forcep
2. Midforcep
3. High Forcep

Purposes:
1. to shorten the 2nd stage of labor
2. prevents excessive pounding of the fetal head against the
perineum
3. prevents exhaustion from a woman’s pushing effect
4. speed delivery in fetal distress
Prerequisites:
1. fully dilated cervix
2. ruptured membranes
3. no CPD
4. empty bladder/rectum

Indications:

C. VACUUM EXTRACTION

Indications:
1. prolonged 2nd stage of labor
2. fetal distress
3. maternal distress Contraindications:
1. fetal scalp blood sampling
2. preterm infants

D. CAESAREAN DELIVERY

Indications:
1. CPD
2. malposition
3. malpresentation
4. previous CS
5. complete or partial placenta previa
6. abruptio placenta
7. prolapsed umbilical cord
8. fetal distress

Types:
1. Low segment -
-
-

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2. Classic -
-
-

• Preparation:
1. NPO
2. Shave or clip pubic hair
3. Insert Foley cath
4. Prepare blood
5. Signed consent

Nursing Care:
1. monitor V/S closely
2. check dressing site
3. inspect perineal pad
4. check fundus for firmness
5. breathing exercises
6. out of bed 1st post op day
7. have the woman hold the baby ASAP HYPERTENSIVE DISORDER OF PREGNANCY

PIH (Pregnancy Induced Hypertension)

Risk Factors:
– primiparas younger than 18 or older than 35
– multipara
– multiple gestation
– family history
• Predisposing Fx:
– low socio-economic status ( poor nutrition )
– underlying disease ( heart disease, diabetes, chronic hypertension )

Manifestations:
1. Mild Pre-Eclampsia
➢ increase systole 30 mmHg
➢ increase diastole 15 mm Hg
➢ mild edema of hands & face
➢ proteinuria 1-2+
➢ wt. gain of 2 lb/wk in 2nd trimester
1 lb/wk in 3rd trimester
2. Severe Pre-Eclampsia
• BP 160/110 mmHg noted on 2 readings at least 6hrs apart
• Proteinuria ( 3-4+ )
• Pitting edema; generalized
• Oliguria
• Severe epigastric pain
• Nausea, vomiting
• Visual disturbances
• Severe headache
• Hyperreflexia

3. Eclampsia
➢ presence of convulsions

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 ➢ coma
➢ cerebral hemorrhage, liver rupture
➢ blurring of vision, severe headache (increased cerebral edema)
➢ hyperactive reflexes

Management:

1. Mild/Severe Pre-Eclampsia
a. bedrest in side lying position
b. quiet & calm environment
c. monitor fetal/maternal well being
d. good nutrition
e. administer meds
• Hydralazine (Apresoline)

• MgSO4 (drug of choice)

- toxic signs
➢ B
➢ U
➢ R
➢ P
➢ Signs of fetal distress
Serum Mg level greater than 2.5 mEq/L
ANTIDOTE:

2. Eclampsia
a. adm O2
b. bed rest - absolute bed rest
- side-lying to drain secretions
- private room, darkened and quiet – near nurse’s station
- no external stimuli
- no visitors
c. external fetal monitor
d. MgSO4 or diazepam
e. termination of pregnancy

OTHER COMPLICATIONS OF PREGNANCY

A. Gestational DM

Risk Factors:
a. family history of diabetes
b. obesity
c. previous macrosomic baby
d. previous infant with anomaly
e. previous unexplained stillbirth

Effects on Pregnancy:
C. increase incidence of UTI

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 D. macrosomia
E. hydramnios
F. congenital anomalies
G. stillbirth
H. abortion

Effects of DM on baby @ birth:

1. Hypoglycemia
- characterized by tremors, lethargy
- occurs 1 to 6 hours after birth

❖ INTRAUTERINE:

❖ EXTRAUTERINE

2. Respiratory Distress Syndrome (RDS)

- also called Hyaline Membrane Disease

• if mother has DM

delay production of phosphatidyl Glycerol

decrease surfactant

RDS

Management:
1. Urine Testing
- check for presence of glucose (Clinistex, Testape)
- check for the presence of ketones (Ketostix, Acetest)

2. Blood Glucose Monitoring

3. Insulin Adm.
Early (1st trimester)
a. increase production of insulin
b. fetus consumes maternal glucose
Late (2nd or 3rd trimester)
a. increased insulin requirement
b. placenta is well developed & produces:
> placental insulinase
> HPL (Human Placental Lactogen)

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 Adm in Combination:
➢ Rapid acting insulin – Regular
➢ Intermediate acting insulin – NPH
• give insulin BID
➢ AM – 30 mins before breakfast
➢ PM – just before dinner

• Type II Diabetic
➢ oral hypoglycemic agent (OHA)

4. Dietary Mgt.
5. Exercise
6. Fetal Surveillance
a. Non-Stress Test (NST)
b. Amniocentesis
c. Oxytocin Challenge Test(OCT) / Contractions Stress Test (CST)

CARDIAC DISEASE

Classifications:
Class I – Asymptomatic with all activity
Class II – Asymptomatic @ rest; symptomatic with heavy physical activity
Class III – Asymptomatic @ rest, symptomatic with ordinary activity
Class IV – Symptomatic with all activity, symptomatic with rest

Effects on the Fetus:

a. retarded growth
b. fetal distress
c. premature labor

Mgt: Goal= to reduce workload of the heart

1. Promote rest

2. Promote a healthy diet

3. Educate regarding meds

a. Digitalis may be given to increase contractility of the heart
b. Penicillin may be given to prevent endocarditis

4. Educate regarding avoidance of infection

5. Promote reduction of psychologic stress

6. Deliver

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