MATERNAL/OB NOTES

I. Human Sexuality A. Concepts 1. A person’s sexuality encompasses the complex behaviors, attitudes, emotions and preferences that are related to sexual self and eroticism. 2. Sex – is basic and dynamic aspect of life 3. During reproductive years, the nurse performs as resource person on human sexuality. B. Definitions related to sexuality: Gender identity – sense of femininity or masculinity 2 - 4 years / 3 years gender identity develops. Role identity – attitudes, behaviors and attributes that differentiate roles. Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse. Sexuality - behavior of being boy or girl, male or female; man or woman. - It is an entity subject to a life long dynamic change. - developed at the moment of conception. II. Sexual Anatomy and Physiology A. Female Reproductive System 1. External - vulva or pudendum a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by short pubic hair that serves as cushion or protection to the symphysis pubis and surrounding delicate tissues from trauma. Tannerscale - tool used to determine sexual maturity rating. Stages of Pubic Hair Development Stage 1 – Pre-adolescence - No pubic hair except for fine body hair only Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly hair along the labia . Stage 3 - occurs between ages 12 and 13 – hair becomes darker & curly hair that develops along symphysis pubis. Stage 4 – occurs between ages 13 and 14. Hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh. Stage 5 - sexual maturity - normal adult - appear to the inner aspect of thigh. b. Labia Majora – means “large lips” - a longitudinal fold, that extends from the symphysis pubis to the perineum; Two folds of skin with fat underneath; contain Bartholene’s glands c. Labia Minora – means “nymphae” – a soft and thin longitudinal fold that is located in between the labia majora; two thin folds of delicate tissues; form an upper fold encircling the clitoris called the prepuce and unite posteriorly called the fourchette. 1

2 sensitive structures of labia minora: c.1. clitoris – means “key”- anterior, pea shaped erectile tissue composed of so many nerve endings which is the sight of sexual arousal in female. (Greek-key) c.2. fourchette - Posterior, tapers posteriorly of the labia minora - very sensitive to manipulation, oftenly torn during vaginal delivery. - common site – episiotomy. d. Vestibule – an almond shaped, narrow space area seen when the labia minora are separated, that contains the hymen, vaginal orifice and bartholene’s glands. i. Urinary Meatus – small opening of urethra that serves for urination; external opening of the urethra; slightly behind and to the side are the openings of the Skene’s Glands. ii. Skenes Glands/or Paraurethral Gland – two small mucous secreting substances that serve for lubrication; often involved in infections of the external genitalia. iii. Hymen – a membranous tissue that covers vaginal orifice, membranous tissue * Carumculae mystiforms - healing of a torn hymen iv. Vaginal Orifice – external opening of vagina v. Bartholene’s Glands/or Paravaginal Gland or Vulvo Gland - 2 small mucus secreting substance that secrets alkaline substances- responsible for the acidity of the vagina. ( Believed to secrete a yellowish mucous which acts as a lubricant during sexual intercourse. The openings are located posteriorly on either side of the vaginal orifice) Alkaline – neutralizes acidity of vagina Ph of vagina - acidic Doderleins bacillus – responsible for acidity of vagina e. Perineum – a muscular structure that is located in between the lower vagina & anus; contains muscles which support the pelvic organs, the arteries that supply blood and the pudendal nerves which are important during delivery under anesthesia. 2. Internal: A. Vagina – female organ of copulation; passageway of menstruation & fetus - it is 3 – 4 inches or 8 – 10 cm long of dilated canal located between the bladder and the rectum. Contains* Rugae – permits considerable amount of stretching without tearing B. Uterus - Organ of menstruation, site of implantation and retainment and nourishment of the products of conception. It is a hollow, thick walled muscular organ. It varies in size, shape and weights. Size - 1 inch thick; 2 inches wide; 3 inches long Shape: non pregnant = pear shaped or inverted avocado Pregnant = ovoid Weight : Non pregnant: – 50 - 60 grams Pregnant: - 1000 grams 4th stage of labor - 1000 grams 2 weeks after delivery - 500 grams 3 weeks after delivery - 300 grams Normal State - 5 - 6 weeks after delivery - 50 – 60 grams Entire Process is “Involution of Uterus”

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Three parts of the uterus 1. fundus - upper cylindrical layer 2. corpus/body - upper triangular layer 3. cervix - lower cylindrical layer * Isthmus – known at the lower uterine segment during pregnancy * Cornua - junction between fundus & interstitial Muscular compositions: there are three main muscle layers which make expansion possible in every direction. 1. Endometrium - inside uterus, in lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs off during menstruation. * Decidua - thick layer; Once implantation has taken place, the uterine endothelium is termed decidua. Occasionally, a small amount of vaginal spotting appears with implantation because capillaries are ruptured by the implanting trophoblasts = implantation bleeding . . . Implication: this should not be mistaken for the LMP(Last Menstrual Period) *Endometriosis – “ectopic endometrium” abnormal proliferation of endometrial lining outside uterus. Common site: ovary. Signs/symptoms: persistent dysmennorhea and low back pain. Diagnostic test: biopsy, laparoscopy Drug of choice: 1. Danazole (Danocrene) Action: a. to stop menstruation b. inhibit ovulation 2. Lupreulide (Lupron) Action: a. inhibit FSH/LH production 2. Myometrium – largest part of the uterus - it is the muscle layer responsible for delivery process - it is a smooth muscles considered to be the living ligature of the body. - power of labor, responsible for the contraction of the uterus 3. Perimetrium – muscle layer that protects entire uterus C. Ovaries – Almond shape, dull white sex glands near the fimbrae, kept in place by ligaments. 2 female sex glands that serves for two functions: 1. ovulation 2. Production of two hormones D. Fallopian tubes – 2 - 3 inches long that serves as a passageway of the sperm from the uterus to the ampulla of the passageway of the mature ovum of fertilized ovum from the ampulla to the uterus. Widest part (ampulla) spreads into fingerlike projections called (fimbrae) responsible for the transport of mature ovum from ovary to uterus; fertilization takes place in its outer third or outer half. 4 significant segments 1. Infundibulum – most distal part of Fallopian Tube, trumpet or funnel shaped, swollen at ovulation 2. Ampulla – outer 3rd or 2nd half, site of fertilization 3. Isthmus – site of sterilization – bilateral tubal ligation 4. Interstitial – most dangerous site of ectopic pregnancy * Cortex of the ovary – releases the matured ovum 3

B. Male Reproductive System 1. External Penis – the male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female – the glands penis.
3 Cylindrical Layers

2 corpora cavernosa 1 corpus spongiosum Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which contains a testes. It is the cooling mechanism of testes - < 2 degrees C than body temperature Leydigs cell – release testosterone * pure sperm plus secreting substance equals SEMEN* 2. Internal The Process of Spermatogenesis – maturation of sperm
Testes – 900 coiled (½ inch long at age 13 onwards) (Seminiferous tubules)

Hypothalamus will release GnRH Gonadotropin releasing hormone Anterior Pituitary Gland release

Epididymis – 6 meters coiled tubules site for maturation of sperm

Vas Deferens – conduit for spermatozoa or pathway of sperm Entry of pure sperm

FSH
Follicle Stimulating Hormone

LF
Luteinizing Hormone

Seminal vesicle – secretes: 1.) Fructose – form glucose that has nutritional value. 2.) Prostaglandin – causes reverse contraction of uterus

Ejaculatory duct – conduit of semen

Function: Sperm Maturation

Function: Hormones for Testosterone Production

Prostate gland - release alkaline substance Cowpers gland - release alkaline substance Urethra Final link from anterior to posterior

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Male and Female homologues Male Penile glans Penile shaft Testes Prostate Cowper’s Glands Scrotum

Female Clitoral glans Clitoral shaft Ovaries Skene’s gands Bartholene's glands Labia Majora

III. Basic Knowledge on Genetics and Obstetrics 1. DNA – carries genetic code 2. Chromosomes – threadlike strands composed of hereditary material known as DNA 3. Normal amount of ejaculated sperm - 3 – 5 cc., 1 tsp 4. Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation 5. Sperm is viable within 48 – 72 hours or 2 - 3 days 6. Reproductive cells divides by the process of meiosis (haploid) Spermatogenesis – maturation of sperm Oogenesis – process - maturation of ovum Gametogenesis – process of formation of 2 haploid into diploid 23 + 23 = 46 or diploid 7. Age of Reproductivity – 15 – 44 years old 8. Menstruation Menstrual Cycle – beginning of menstruation to the beginning of the next menstruation Average Menstrual Cycle – 28 days Average Menstrual Period - 3 – 5 days Normal Blood loss – 50 cc or ¼ cup with fibrinolysin to prevent clot formation Related terminologies: Menarche – the beginning or the 1st menstruation Dysmenorrhea – painful menstruation Metrorrhagia – bleeding at completely irregular intervals of menstruation Polymenorrhea – frequent menstruation occurring at intervals of less than three weeks Menorhagia – excessive bleeding during regular menstruation Amenorrhea – absence of menstruation Oligomenorrhea – marked diminished menstrual flow, nearing amenorrhea Menopause – cessation of menstruation / average : 51 years old 9. Functions of Estrogen and Progestin * Estrogen “Hormone of the Woman” Primary function: responsible for the development of secondary sexual characteristic of female. • enlargement of the breast • pelvic • axillary • pubic hair Others: 1. inhibit production of FSH ( maturation of ovum) 2. responsible for the hypertrophy of myometrium 3. responsible for Spinnbarkeit & Ferning ( billings method/ cervical) 4. responsible for the development of ductile structure of the breast 5. responsible for the increase osteoblast activities of long bones causing increase in height in female 6. responsible for the early closure of epiphysis of long bones 7. responsible for sodium retention 5

8. responsible for the increase sexual desire * Progestin “ Hormone of the Mother” Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous (twisted) Secondary Function: It decreases contractility of the uterus (favors pregnancy) Others: 1. It inhibit the production of LH (hormone for ovulation) 2. It decreases GIT motility ↓ decreases Peristalsis ↓ increase Water Reabsorption ↓ CONSTIPATION 3. responsible for the development of mammary gland 4. responsible for the increase permeability of kidney to lactose & dextrose causing (+) sugar 5. responsible for mood swings in woman 6. responsible for the increase Basal Body Temperature 10. Menstrual Cycle: average – 28 days 4 phases of Menstrual Cycle 1.1. Proliferative 1.2. Secretory 1.3. Ischemic 1.4. Menses Parts of body responsible for menstruation: 1. hypothalamus 2. anterior pituitary gland – masterclock of the body 3. ovaries 4. uterus I. Initial phase – of menstruation, the estrogen level is ↓ , this level stimulates the hypothalamus to release GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone Releasing Factor) 3rd day – Decreased estrogen 13th day – Peak estrogen, Decrease progesterone 14th day – Increase estrogen, Increase progesterone 15th day – Decrease estrogen, Increase progesterone II. GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone Releasing Factor) – stimulates the anterior pituitary gland to release FSH (Follicle Stimulating Hormone) Functions of FSH: A. Stimulate ovaries to release estrogen B. Facilitate growth primary follicle to become graffian follicle (structures that secrets large amount of estrogen & contains mature ovum.) Proliferative Phase – contains mature ovum (ovulation) proliferation of tissue → follicular phase → post menstrual phase → Preovularoty Phase Follicular Phase – causing irregularities or variations of menstruation; 14th days Postmenstrual Phase – occurs after menstruation day Preovulatory Phase – happens before menstruation day 6

III.

“ all phases – increase ESTROGEN” IV. V. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these stimulates the hypothalamus to release GnRH or LHRF (Luteinizing Hormone Releasing Factor) GnRH/LHRF stimulates the anterior pituitary gland to release LH(Luteinizing Hormone) Functions of LH: 1. LH stimulates ovaries to release progesterone 2. hormone for ovulation 14th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of ovulation. Signs and symptoms: 1.) Mittelschmerz – slight abdominal pain on Left or Right lower Quadrant of abdomen, marks ovulation day. 2.) Change in Basal Body Temperature 3.) Mood Swing 4.) Constipation 15th day, after ovulation day, graafian follicle starts on degenerate becoming yellowish known as corpus luteum (secretes large amount of progesterone) Secretory phase Lutheal Phase Postovulatory Increased progesterone Premenstrual • Secretory Phase – secretes the most important hormone in pregnancy which is the progesterone because it makes the uterus nutritionally abundant with blood in order for the fertilized zygote to survive should conception take place. It is also called progestational phase. • Luteal Phase – change from Graafian follicle to Corpus Luteum(yellowish appearance) • Postovulatory Phase – occurs just after ovulation • Premenstrual Phase – occurs after menstruation

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VII. VIII.

IX. 24th day - no fertilization, corpus luteum degenerate turning white ( whitish – corpus albicans) X. 28th day – no sperm in ovum – endometrium begins to slough off to have the next menstrual period 1st 7 days – menstrual phase 7 – 14th days – proliferative phase 14 – 28 days – secretory phase 11. Stages of Sexual Responses (EPOR) Initial responses: Vasocongestion – congestion of blood vessels Myotonia – increase muscle tension 1. Excitement Phase – (moderate vital signs : sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) – during this phase: erotic stimuli increase sexual tension that may lasts from minutes to hours. 2. Plateau Phase – (accelerated Vital Signs) – increasing & sustained tension nearing orgasm. May lasts 30 seconds – 3 minutes. 3. Orgasm – (involuntary spasm throughout the body, peak vital signs). This is the involuntary release of sexual tension accompanied by physiologic and psychologic release known as “immeasurable peak of sexual experience”. 7

May last from 2 – 10 sec- most affected are is pelvic area. 4. Resolution – (vital sign return to normal, genitals return to pre-excitement phase) Refractory Period – the only period present in males, wherein he cannot be restimulated for about 10 - 15 minutes IV. Wonders of Fertilization Fornix - where sperm is deposited Sperm - small head, long tail, pearly white Phonones -vibration of head of sperm to determine location of ovum Sperm should penetrate corona radiata and zona pellocida. Capacitation - ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona pellocida. A. Fertilization – union of the sperm and the mature ovum in the outer third or outer half of the Fallopian Tube. General Consideration: 1. Normal amount of semen per ejaculation - 3 – 5 cc = 1 teaspoon 2. Number of sperms in an ejaculate = 120 – 150 million/cc 3. Mature ovum is capable of being fertilized for 24 – 36 hours after ovulation. 4. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation 5. Sperm is viable within 48 – 72 hours or 2 – 3 days 6. Normal lifespan of sperm = 7 days 7. Sperms, once deposited in the vagina, will generally reach the cervix within 90 seconds after deposition. 8. Reproductive cells, during gametogenesis, divide by meiosis (haploid number of daughter cells); therefore, they contain only 23 chromosomes ( the rest of the body cells have 46 chromosomes ). Sperms have 22 autosomes and 1 X sex chromosomes or 1 Y sex chromosome; Ovum contain 22 autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a mature ovum results in a baby girl (XX); the union of a Y-carrying sperm and mature ovum results in a baby boy (XY). Important: Only “fathers” determine the sex of their children B. Stages of Fetal Growth and Development 3 - 4 days travel of zygote → during the travel → mitotic cell division begins *Pre-embryonic Stage a. Zygote - fertilized ovum. Lifespan of zygote – from fertilization to 2 months fetus - 2 months to birth b. Morula – mulberry-like ball with 16 – 50 cells, start to travel by ciliary action and peristaltic contractions of fallopian tube to the uterus where it will stay for 4 days free floating & multiplication c. Blastocyst – enlarging cells that forms a cavity in the morulla, that later becomes the embryo. Trophoblast – fingerlike projections covering around the blastocyst that later becomes placenta and membrane. d. Implantation other term Nidation - occurs after fertilization 7 – 10 days. Placenta previa – implantation at the lower side of the uterus Signs of implantation: 1. slight pain 2. slight vaginal spotting - if with fertilization – corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed. * 3 processes of Implantation 1. Apposition – blastocysts begin to brush the endothelial lining 2. Adhesion – blastocysts begin to attached the endothelial lining 8

3. Invasion – blastocysts begin to settle down “Proteolytic enzyme” – for dissolving endothelial lining allowing implantation * Embryonic Stage C. Decidua – thickened endometrium (Greek word – falling off); implantation has taken place Kinds of decidua: * Basalis (base) part of endometrium located directly beneath or under the implanted ovum/fetus where placenta is developed. * Capsularies – encapsulate or co the fetus * Vera – remaining portion of endometrium. D. Chorionic Villi - 10 – 11th day of pregnancy; fingerlike projections 3 vessels = two arteries, one vein A – unoxygenated blood V – O2 blood A – unoxygenated blood Wharton’s jelly – protects cord Chorionic Villi Sampling (CVS) – removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common dangerous side effects: fetal limb defect such as missing digits/toes. Advance Maternal Age – candidate for amniocentesis E. Cytotrophoblast – inner layer or langhans layer of the trophoblast that gives rise to the outer surface and villi of the chorion. - protects fetus against syphilis, however it can be capable of living for 24 weeks/6 months - life span of langhans layer increase. * Before 24 weeks critical, might get infected syphilis F. Syncytiotrophoblast – syncytial layer or outer layer . It erodes the uterine wall during implantation and give rise to the villi of the placenta. It is responsible production of hormones. It is also called plasmidotrophoblast; syncytial trophoblast, syntrophoblast Two structures developed: 1. Amnion – innermost layer. It is a membrane, continuous with and covering the fetal side of the placenta that forms the outer surface of the umbilical cord. 2 structures progress: a. Umbilical Cord other term chorda umbilicalis, funiculus umbilicans, funis, a flexible structure connecting the umbilicus with the placenta in the gravid uterus and giving passage to the umbilical arteries and vein; whitish grey, “15 – 55 cm, 20 – 21”. *Importance of determining the length of the cord: Short cord: abruptio placenta or inverted uterus. Long cord: cord coil or cord prolapse Newborn: 2 feet long and ½ inch in diameter; 1st formed during the 5th week of pregnancy; it contains the yolk sac and the body stalk with enclosed allatois. b. Amniotic Fluid , also known as (BOW) bag of water, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline. *Function of Amniotic Fluid: 1. cushions fetus against sudden blows or trauma 2. facilitates musculo - skeletal development and symmetrical growth 3. maintains temperature 4. prevent cord compression 5. help in delivery process normal amount of amniotic fluid – 500 to 1000cc polyhydramnios, hydramnios - GIT malformation (TEA) Tracheoesophageeal Atresia /(TEF) Tracheoesophageal Fistula, increased amount of fluid 9

oligohydramnios- decrease amount of fluid – kidney disease; “inom → absorbed → ihi” Diagnostic Tests for Amniotic Fluid A. Amniocentesis – aspiration of amniotic fluid - empty bladder before performing the procedure. Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac. Fluid is tested for: 1. Genetic screening / abnormality - maternal serum alpha feto-protein test (MSAFP) – 1st trimester 2. Determination of fetal lung maturity primarily by evaluating factors indicative of lung maturity – 3rd trimester 2.1 Testing time – 36 weeks decreased MSAFP(maternal serum alpha feto-protein test) = down syndrome increase MSAFP(maternal serum alpha feto-protein test) = spina bifida or open neural tube defect Common infections amniocenthesis – infection Dangerous complications – spontaneous abortion / bleeding 3rd trimester- pre term labor; indication of diabetic mother Important factor to consider for amniocentesis - needle insertion site Aspiration of yellowish amniotic fluid – jaundice baby / hyperbilirubin Greenish – mecomium A. Amnioscopy – direct examination thru an intact fetal membrane. B. Fern Test - determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid) C. Nitrazine Paper Test – diff amniotic fluid & urine. Paper turns yellow- urine. Paper turns blue green/gray -(+) rupture of amniotic fluid. 2. Chorion – where placenta is developed – outermost membrane Lecithin Sphingomyelin L/S Ratio - 2:1 signifies fetal lung maturity not capable for RDS(Respiratory Distress Syndrome) Test for Fetal Lung Maturity: Shake test – amniotic + saline & shake Foam test – amniotic + saline & shake Phosphatiglycerol: PG+ definitive test to determine fetal lung maturity a. Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis. - Size: 500g or ½ kg - 15 – 28 cotyledons -1 inch thick & 8” diameter Functions of Placenta: 1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion “ Higher Concentration to Lower Concentration” 2. GIT – transport center, glucose transport is facilitated diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic “Higher to Lower Concentration but RAPID” 3. Excretory System- artery - carries waste products. Liver detoxifies waste products of the fetus. 4. Circulating system – achieved by selective osmosis

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5. Endocrine System – produces hormones • Human Chorionic Gonadrophin – maintains corpus luteum alive; basis of pregnancy test • Human placental Lactogen or sommamommamotropin Hormone – for mammary gland development. Has a diabetogenic effect – serves as insulin antagonist • Relaxin Hormone- causes softening joints & bones • estrogen • progestin 6. It serves as a protective barrier against some microorganisms – HIV,HBV Entire pregnancy days – 266 – 280 days 37 – 42 weeks 280 divided by 28 = 10 lunar months 280 divided by 31 days = 9.7 days (calendar months) 1st week counted “zero” Fetal Stage “ Fetal Growth and Development” First trimester: period of organogenesis; most critical period First Month - Brain & heart development GIT & respiratory Tract – remains as single tube 1. Fetal heart tone begins – heart is the oldest part of the body 2. CNS develops – dizziness of mother due to hypoglycemic effect Food of brain – glucose complex CHO – pregnant woman’s food (potato) Differentiation of Primary Germ layers * Endoderm 1st week endoderm – primary germ layer Thyroid – for basal metabolism; respiratory Parathyroid - for calcium metabolism Thymus – development of immunity Liver Lining of upper Respiratory Tract & Gastro Intestinal Tract * Mesoderm – development of heart, musculoskeletal system, kidneys and reproductive organ * Ectoderm – development of brain CNS, skin and 5 senses, hair, nails, mucous membrane of anus & mouth Second Month 1. All vital organs formed, placenta developed 2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month 3. Sex organ formed 4. Meconium is formed Third Month 1. Kidneys functional 2. Fetus begin to swallow amniotic fluid 3. Buds of milk teeth appear 4. Fetal heart tone heard – Doppler – 10 – 12 weeks 5. Sex is distinguishable 11

Second Trimester: FOCUS – length of fetus Fourth Month 1. lanugo begins to appear 2. fetal heart tone heard fetoscope, 18 – 20 weeks 3. buds of permanent teeth appear Fifth Month 1. lanugo covers body 2. actively swallows amniotic fluid 3. 19 – 25 cm fetus, 4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16 - 18 weeks – multi 5. fetal heart tone heard with or without instrument Sixth Month 1. eyelids open 2. wrinkled skin 3. vernix caseosa present Third trimester: Period of most rapid growth. FOCUS: weight of fetus Seventh Month – development of surfactant – lecithin Eighth Month 1. lanugo begin to disappear 2. subcutaneous fats deposit 3. Nails extend to fingers Ninth Month 1. lanugo & vernix caseosa completely disappear 2. Amniotic fluid decreases Tenth Month – bone ossification of fetal skull Teratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus A. Drugs: Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing & deafness Tetracycline – staining tooth enamel, inhibit growth of long bone Vitamin K – lead to hemolysis (destruction of RBC); hyperbilirubenia or jaundice Iodides – enlargement of thyroid or goiter Thalidomides – Amelia – totally no extremities Pocomelia - absence of distal part of extremities Steroids – cleft lip or cleft palate or even abortion Lithium – congenital malformation B. Alcohol – low birth weight (vasoconstriction on mother), fetal alcohol withdrawal syndrome charterized by microcephaly C. Smoking – low birth weight D. Caffeine – low birth weight abruption placenta 12

E. Cocaine – low birth weight

V.

TORCH (Terratogenic) Infections – viruses CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely effect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some cases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus. T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat O – others. Hepa A or infectious heap – oral/ fecal (hand washing) Hepa B, HIV – blood & body fluids Syphilis R – rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10 < 1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Avoid pregnancy for 3 months because Vaccine is terratogenic; Notify the doctor C – cytomegalo virus (CMV) H – herpes simplex virus Physiological Adaptation of the Mother to Pregnancy A. Systemic Changes 1. Cardiovascular System – beginning the end of the 1st trimester, there is a gradual increase blood volume of mom ( plasma blood ) 30 – 50% = 1500 cc of blood - easy fatigability, increase heart workload, slight hypertrophy of ventricles, - epistaxis due to hyperemia of nasal membrane - palpitation due to stimulation of parasymphathetic nervous system Physiologic Anemia – pseudo anemia of pregnant women Normal Values Hct 32 – 42% Hgb 10.5 – 14g/dL Criteria 1st and 3rd trimester.- pathologic anemia if lower Hct should not fall below 33% Hgb should not fall below 11g/dL 2nd trimester – Hct should not fall below 32% Hgb should not fall below 10.5% pathologic anemia if lower Pathogenic Anemia - iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women. Assessment reveals: • Pallor, constipation • Slowed capillary refill • Concave fingernails (late sign of progressive anemia) due to chronic physiologic hypoxia 13

Nursing Care: • Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetablealugbati, saluyot, malunggay, horseradish, ampalaya • Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered, hematoma. • Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hours after, black stool, constipation • Monitor for hemorrhage Alert: • Iron from red meats is better absorbed iron form other sources • Iron is better absorbed when taken with foods high in Vitamin C such as orange juice • Higher iron intake is recommended since circulating blood volume is increased and hemoglobin is required from production of RBCs Edema – occurs because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities due venous return is constricted due to large belly. Management: elevate / raise legs above hip level. Varicosities – pressure of uterus Management: - use support stockings, avoid wearing knee high socks - use elastic bandage – lower to upper Vulbar varicosities - painful, pressure on gravid uterus, Management: to relieve- position – side lying with pillow under hips or modified knee chest position Thrombophlebitis – presence of thrombus at inflamed blood vessel - pregnant mom hyperfibrinogenemia - increase fibrinogen - increase clotting factor - thrombus formation candidate outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens Management: 1.) Complete Bed rest 2.) Never massage 3.) Assess + Homan sign once only might dislodge thrombus 4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute) 5.) Monitor APTT - Heparin toxicity : protamine sulfate(antidote for heparin) 6.) Avoid aspirin! Might aggravate bleeding. Respiratory system – common problem Shortness Of Breathing due to enlarged uterus & increase O2 demand Management: Position: lateral expansion of lungs or side lying position. Gastrointestinal – 1st trimester change * Morning Sickness – nausea & vomiting due to increase HCG. Management: • Eat dry crackers or dry CHO diet 30 minutes before arising bed. 14

2. 3.

Nausea afternoon - small frequent feeding.

o Vomiting in pregnancy – emesisgravida. o Excessive Vomiting - hyperemesisgravidarum Metabolic alkalosis, Fluids &Electrolytes imbalance primary medical management – Replace Fluids. - Monitor Input & Output * Constipation – progesterone responsible for constipation. Management: * Increase fluid intake * Increase fiber diet : fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha, except guava – has pectin for constipating vegetables – petchay, malunggay, swamp cabbage (kangkong) * Exercise * Mineral Oil – excretion of fat soluble vitamins * Flatulence – avoid gas forming food such as cabbage, camote * Heartburn or “ pyrosis” – reflux of stomach content to esophagus Management: - small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk at frequent interval, proper body mechanical - increase salivation – ptyalsim – management: mouthwash * Hemorrhoids – pressure of gravid enlarged uterus. Management: • hot sitz bath for comfort • cold compression with witch hazel or EPSOM salts 4. Urinary System frequency of urination - during 1st & 3rd trimester management for nocturia: lateral expansion of lungs or side lying position Nocturia – urination during night time Heat Acetic Acid test – is a test to determine the presence of albumin and protein in urine Benedict’s test – test used to determine sugar in urine 5. Musculoskeletal “Lordosis” – (Greek: lordos - bent forward; osis - condition) also known as the “pride of pregnancy” - an abnormal anterior concavity of the lumbar part of the back; inward curvature of the spine “Waddling Gait” – characterized by exaggerated lateral trunk movements and hip elevation which can be observed in a pregnant patient. - awkward walking of a pregnant mother, candidate for accidental fall due to relaxation and the hormone responsible for this gait is Relaxin – responsible for softening of joints & bones; Prone to accidental falls Management – wear flat / no heels shoes Pregnant mothers can develop “Leg Cramps” – causes: prolonged standing, over fatigue, Ca & phosphorous imbalance ( #1 cause while pregnant ), chills, oversex, pressure of gravid uterus ( labor cramps ) at lumbo sacral nerve plexus Note: 15

Leg cramps during labor is due to pressure of gravid uterus Leg cramps during pregnancy is due to decrease calcium and increase phosphorus Management: Food That Are Rich in Calcium: 1. Increase Ca diet - milk ( Increase Ca & Increase phosphorus ) -1 pint/day or 3 - 4 servings/day. Note: there’s still a tendency that a mother will experience leg cramps due to high level of phosphorus 2. Cheese, yogurt, and dairy products 3. head of fish, Dilis, sardines with bones, broccoli, seafood such as tahong (mussels), lobster, crab. 4. Vegetable – broccoli Management: Place the foot affected then dorsiflexion Note: Vitamin D for increased Ca absorption B. Local Changes 1. Vagina – Chadwick’s sign (color change of the vagina from pink to violet) – blue violet discoloration of vagina Cervix – Goodell's sign (softening of the cervix) – change of consistency of cervix Uterus – Hegar's sign (softening of the lower uterine segment) – change of consistency of isthmus (lower uterine segment) LEUKORRHEA – whitish gray, mousy odor discharge ESTROGEN – hormone, responsible for leukorrhea (remember the second letter of Leukorrhea) OPERCULUM – mucus plug to seal out bacteria. PROGESTERONE – hormone responsible for operculum ( remember the second letter of Operculum ) Problems Related to the Change of Vaginal Environment: a. Vaginitits – caused by Trichomonas Vaginalis, a flagellated protozoa, local infection of the vagina, due to alkaline environment of vagina of pregnant mom – acidic to alkaline change to protect bacterial growth (vaginitis) “Flagellated protozoa – wants alkaline” Signs &Symptoms: Greenish cream colored and frothy discharge, irritatingly itchy with foul smelling odor accompanied by vaginal edema Management Drug of Choice : FLAGYL – (Metronidazole – antiprotozoa). Note: not to be given to pregnant mothers on her 1st trimester due to Carcinogenic effects. 1. on the 2nd and 3rd trimester – flagyl can be given 2. treat dad also to prevent reinfection 3. avoid alcohol, antabuse drus – has antibuse effect VAGINAL DOUCHE – I quart of water and 1 tbsp white vinegar

16

b. Moniliasis or Candidiasis – caused by Candida Albicans also called Candidiasis, fungal infestation. Signs & Symptoms: Color – white cheeselike patches adheres to the walls of vagina, extreme pruritus Management : antifungal – Nistatin, gentian violet, cotrimaxole, canesten Gonorrhea - Thick purulent discharge Vaginal warts - condifoma acuminata due to papilloma virus Management: cauterization 2. Abdominal Changes * striae gravidarium (stretch marks) due to enlarging uterus brought by destruction of subcutaneous tissue. Nursing Care: Instruct to avoid scratching and application of oil * umbilicus is protruding 3. Skin Changes * Chloasma/ Melasma – white or light brown pigmentation in the nose, chin, cheeks due to increased melanocytes. * Linea Nigra – brown pinkish line running from symphisis pubis to umbilicus

4. Breast Changes – all breast changes are related to change and increase in hormones - size and color of areola & nipple change pre colostrums present by 6 weeks, colostrums at 3rd trimester BSE (Breast self exam) - one week or 7 days after menstruation Position: supine with pillow at back quadrant B – upper outer – common site of cancer Test to determine breast cancer: Mammography – 35 to 49 years old should submit to mammography once every 2 years 50 years old and above – once a year 5. 6. Ovaries – rested during pregnancy; no significant changes Signs & symptoms of Pregnancy A. Presumptive – signs and symptoms felt and observed by the mother but does not confirm positive diagnosis of pregnancy : Subjective B. Probable – signs observed by the members of health team: Objective C. Positive Signs – undeniable signs confirmed by the use of instrument. Ballotement sign of myoma * + HCG – sign of H mole - trans vaginal ultrasound. Empty balder - ultrasound – full bladder placental grading – rating/grade 0 – immature 1 – slightly mature 2 – moderately mature 3 – placental maturity 17

What is deposited in placenta which signify maturity - there is calcium Presumptive 1st Trimester Breast changes Urinary frequency Probable Goodel's- change of consistency of cervix Chadwick’s- blue violet discoloration of vagina Positive Ultrasound evidence (sonogram) full bladder Transvaginal – empty bladder

Fatigue Amenorrhea Morning sickness Enlarged uterus 2nd Trimester Cloasma Linea negra Increased skin pigmentation Striae gravidarium Quickening

Hegar's- change of consistency of isthmus Elevated BBT – due to increased progesterone Positive HCG or (+)pregnnacy test Ballottement – bouncing of fetus when lower uterine is tapped sharply, sign of myoma Enlarged abdomen Braxton Hicks contractions – painless irregular contractions Fetal heart tone Fetal movement Fetal outline on x-ray Fetal parts palpable

VI. Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory) First Trimester: • No tanginal signs & symptoms, surprise, ambivalence, denial • Sign of mal adaptation to pregnancy Developmental task: is to accept biological parts of pregnancy Health Teaching: bodily changes of pregnancy, Focus: nutrition and on growth and development Second Trimester • tangible Signs & Symptoms: mother identifies fetus as a separate entity due to presence of quickening, fantasy. Developmental task: to accept growing fetus as baby to be nurtured. Focus: growth & development of fetus. Third Trimester: - mother has personal identification on appearance of baby Development task: prepare of birth & parenting of child. Health Teaching: responsible parenthood Best for ‘baby’s Layette” – best time to do shopping. Most common fear about moms fetus – let mother listen to Fetal Heart Tone to allay fear - Lamaze classes VII. Pre-Natal Visit: Basic Considerations: 1. Frequency of Visit:

1st 7 months – once a month 8 – 9 months – twice a month 10 – once a week (weekly) 18

post term - twice a week

2. Personal data: Name: for identification Age: to determine if the mother is in high risk (high risk < 18 & >35 yrs old) (HBMR) Home Base Mother’s Record – tool used to determine high risk pregnancy Sex: PSEUDOCYESIS – false pregnancy common to male COUVADE SYNDROME – psychosomatic reaction wherein the father experiences the mother goes through; the father is the one to vomits,etc – (lihi) Religion: for their culture & beliefs with respect, non judgmental Occupation: financial condition or occupational hazards Education Background: to determine level knowledge Address; civil status 3. Diagnosis of Pregnancy 1.) urine exam to determine HCG - 6 weeks after Last Menstrual Period , 40 – 100th day but peak 60 – 70 day best to get urine exam. 2.) Elisa test – test to detect beta subunit of HCG as early as 7 – 10 days 3.) Home pregnancy kit – do it yourself 4. Baseline Data: Vital Signs especially Blood Pressure Monitor weight (increase weightt – 1st sign preeclampsia), pattern of weight gain/loss is important Weight Monitoring First Trimester: Second trimester: Third trimester: Normal Weight gain 1.5 – 3 lbs Normal Weight gain 10 – 12 lbs Normal Weight gain 10 – 12 lbs Average weight gain – 20 – 25 lbs Optimal weight gain – 25 – 35 lbs ( .5 – 1 lb/month ) (4 lbs/month) (1 lb/wk) (4 lbs/ month) ( 1lb/wk)

5. Obstetrical Data: nullipara – no pregnancy a. Gravida - number of pregnancies, 2 children G2 b. Para - number of viable pregnancies, 2 viable P2 Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age. Age of Viability - 20 – 24 weeks Term - 37 – 42 weeks Preterm - 20 – 37 weeks Abortion < 20 weeks Sample Cases: a. 1 – abortion 1 – 2nd month pregnant b. 1 – 40th AOG 1 – 36th AOG 2 – miscarriage 1 – twins 35th AOG G2T0P0A1L0 G2P0 G6T1P2 A 2L4 G6 P3

19

1 – 4th month pregnant

c. 1 – 39th week 1 – miscarriage 1 – stillbirth 33 AOG (considered as para) 1 – pregnant 3rd wk d. 1 – 33rd P 1 - 41st L 1 – abortion A 1 – stillbirth 39th 1 - triplet 32nd 1 - 4th month pregnant e. 1 – 39th AOG 1 – miscarriage 1 – stillbirth 33rd AOG 1 – 3rd month pregnant

G4P2 G4T1P1A1L1

G6T2P2A1L5 G6P4

G4P1 G4T1P1A1L1

f. 1 – 40th AOG 1 – Abortion 1 – twin 37th AOG 1 – 4th month pregnant g. 1 – 38th AOG 1 – 37th AOG 1 – Abortion c. Important Estimates: 1 – Triplets 30th AOG 1 – 32nd AOG 1 – Stillbirth 42nd AOG

G4P2 G4T1P1A1L3

G6P5 G6T3P2A1L6

1. Nagele’s Rule – used of determine expected date of delivery January, February and March - +9+7 while April to December - -3+7+1 Get Last Menstrual Period -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar M D Y +9 +7 no year Example: a. LMP January 03, 2005 01 03 05 + 09 07___ 10-10-05= Expected Date of Confinement October 10, 2005 b. LMP August 04, 2005 08 04 05 -03+07+01 05-11-06= EDC May 11, 2006 2. McDonald’s Rule – used to determine age of gestation IN WEEKS Get the length in cm x 7/8 = AOG in weeks FUNDIC HT X 7/8=AOG in weeks 20

Fundic Ht X 7 = AOG in weeks 8 From symphysis pubis to fundus 24 X 7 =21 wks 8

3. Bartholomew’s Rule – used to determine age of gestation of the fetus by proper location of fundus at abdominal cavity. 3 months – above symphysis pubis 5 months – level of umbilicus 9 months – below xiphoid 10 months – level of 8 months due to lightening 4. Haases rule – used to determine length of the fetus in cm. Formula: 1st ½ of preg , square @ month 2nd ½ of preg, x @ month by 5 3mos x 3 = 9cm 4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg 5 x 5 = 25 cm 6 x 5 = 30 cm 7 x 5 = 35 cm 2nd ½ of preg 8 x 5 = 40 cm 9 x 5 = 45 cm d. Tetanus Immunizations – prevents tetanus neonatum - mother with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3 TT1 – any time during pregnancy TT2 – 4 weeks after TT1 – 3 yrs protection TT3 – 6 months after TT2 – 5 yrs protection TT4 – 1 year after TT3 – 10 yrs protection TT5 – year after TT4 – lifetime protection Note: if the mother received 3 doses of DPT during childhood, she will be given TT3. 5. Physical Examination: Cephalocaudal including the teeth * Examine teeth: sign of infection Danger signs of Pregnancy: C - chills/ fever - infection - Cerebral disturbances ( headache – preeclampsia) A – abdominal pain ( epigastric pain) – aura/alert of impending convulsions B – boardlike abdomen – sign of abruption placenta Increase BP – HPN(hypertension) Blurred vision – pre eclampsia Bleeding : 1st trimester - abortion, ectopic pregnancy 2nd trimester – H mole, incompetent cervix 3rd trimester – any placental anomalies such as abruption placenta, placenta previa S – sudden gush of fluid – PROM (premature rupture of membrane) prone to infection. - swelling/edema of upper extremities (pre eclampsia) 21

6. Pelvic Examination : Internal Examination Preparation: 1. empty bladder 2. universal precaution On the first visit the mother will examined internally in order to determine the presence of probable signs such as Chadwick, Goodels and Hegar’s sign. Pap Smear – cytological examination to determine the presence of cancer cells External OS of cervix – site for getting specimen ; composed of squamous columnar tissue; Site for cervical cancer Vaginal Speculum will be needed, to avoid contact from other organ Result: Class I - normal Class IIA – suggestive of inflammation B - acytology but no evidence of malignancy Class III – cytology suggestive of malignancy Class IV – cytology strongly suggestive of malignancy Class V – cytology conclusive of malignancy Stages of Cervical Cancer Stage 0 – carcinoma insitu 1 – cancer confined to cervix 2 - cancer extends to vagina 3 – pelvis metastasis 4 – affectation to bladder & rectum 7. Leopold’s Maneuver Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone; use palm! Warm palm. Preparation for mothers: 1. Empty bladder 2. Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles) Procedure: 1st maneuver: Place patient in supine position with knees slightly flexed; Put towel under head and right hip; With both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part. In dorsal recumbent position – to relax the abdominal muscles. To determine presentation parts. 2nd Maneuver: with both hands moving down, identify the back of the fetus (to hear fetal heart sound) where the ball of the stethoscope is placed to determine Fetal Heart Tone. Get Vital Signs (before 2nd maneuver) Pulse Rate to differentiate fundic soufflé (Fetal Heart Rate) & uterine soufflé (Maternal Heart Rate). To determine fetal back. 22

3rd Maneuver: using the right hand, grasp the symphysis pubis part using thumb and fingers. To determine degree of engagement. (Assess whether the presenting part is engaged in the pelvis ) Alert : if the head is engaged it will not be movable.

4th Maneuver: the Examiner changes the position by facing the patient’s feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head will be flexed and vertex presenting. To determine attitude – relationship of fetus to 1 another. Attitude – refers to the relationship of fetus to each part into one another ( degree of flexion ) Full flexion – when the chin touches the chest 8. Assessment of Fetal Well-BeingA. Daily Fetal Movement Counting (DFMC) – begin 27 weeks Mother - begin after meal – breakfast a. Cardiff count to 10 method – one method currently available (1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs) (2) Expected findings – 10 movements in 1 hour or less (3) Warning signs a.) more than 1 hour to reach 10 movements b.) less than 10 movements in 12 hours (non-reactive- fetal distress) c.) longer time to reach 10 (FMs) fetal movements than on previous days d.) movement are becoming weaker, less vigorous * Movement alarm signals - < 3 FMs in 12 hours (4.) Warning signs should be reported to healthcare provider immediately; often require further testing. Examples: non stress test (NST), biophysical profile (BPP) b. Nonstress test – to determine the response of the fetal heart rate to activity Indication – pregnancies at risk for placental insufficiency Postmaturity a.) Pregnancy Induced Hypertension (PIH), diabetes b.) Warning signs noted during DFMC c.) Maternal history of smoking, inadequate nutrition Procedure: Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor);external monitor is applied to document fetal activity; mother activates the “mark button” on the electronic monitor when she feels fetal movement. Attach external noninvasive fetal monitors 1. Tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) 2. Ultrasound Transducer over abdominal site where most distinct fetal heart sounds are detected 3. Monitor until at least 2 FMs are detected in 20 minutes 23

• •

if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen if no FM after 1 hour further testing may be indicated, such as a CST

Result: Noncreative Nonstress Not Good Reactive Responsive is Real Good Interpretation of results i. Reactive Result 1. Baseline FHR between 120 and 160 beats per minute 2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds in a 10 to 20 minutes period as a result of Fetal Movement 3. Good variability – normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip. 4. result indicates a healthy fetus with an intact nervous system ii. Nonreactive Result 1. Stated criteria for a reactive result are not met 2. Could be indicative of a compromised fetus. Requires further evaluation with another nonstress test NST, biophysical profile, (BPP) or Contraction Stress Test (CST) 9. Health Teachings : do nutritional assessment a. Nutrition – daily food intake High risk mothers: 1. Pregnant teenagers – very long compliance to health regimen. 2. Extreme weight Underweight: malnourished like elite model Over weight : candidate for HPN, DM 3. Mothers with low socio – economic status – refer to DSWD 4. Vegetarian mothers – decrease CHON – needs Vitamin B12/folic acid – cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation. (Decrease folic acid – spina bifida/open neural tube defect, meningocele umphalocele) Types of Vegetarian: 1. Strict Vegetarian – vegetables only ( with rigid personality) 2. Lactovegetarian – vegetables/milk 3. Lactoovovegetarian – vegetables/milk/egg How many calorie : CHO x 4, CHON x 4, FATS x 9 Daily Calorie Intake : Non Pregnant – 2,200 24

Add - 300 Pregnant – 2,500 During Lactation Add - 500

VIII. Recommended Nutrient Requirement that increases During Pregnancy Requirements Calories 300 calories/day above the preEssential to supply energy for pregnancy daily requirement to - increased metabolic rate maintain ideal body weight and - utilization of nutrients meet energy requirement to activity - protein sparing so it can level be used for - Begin increase in second - Growth of fetus trimester - Development of structures - Use weight – gain pattern as required for pregnancy an indication of adequacy of including placenta, calorie intake. amniotic fluid, and tissue - Failure to meet caloric growth. requirements can lead to ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage. Protein Essential for: - Fetal tissue growth - Maternal tissue growth including uterus and breasts - Development of essential pregnancy structures - Formation of red blood cells and plasma proteins * Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH) Calcium-Phosphorous Essential for - Growth and development of fetal skeleton and tooth buds - Maintenance of mineralization of 60 mg/day or an increase of 10% above daily requirements for age group Adolescents have a higher protein requirement then mature women since adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement Nutrients Food Source Caloric increase should reflect - Foods of high nutrient value such as protein, complex carbohydrates (whole grains, vegetables, fruits) - Variety of foods representing foods sources for the nutrients requiring during pregnancy - No more than 30% fat

Protein increase should reflect - Lean meat, poultry, fish - Eggs, cheese, milk - Dried beans, lentils, nuts - Whole grins * vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids

Calcium increases of Calcium increases should reflect: - 1200 mg/day representing an - dairy products : milk, yogurt, ice increase of 50% above precream, cheese, egg yolk pregnancy daily requirement. - whole grains, tofu - 1600 mg/day is recommended - green leafy vegetables for the adolescent. 10 mcg/day - canned salmon & sardines w/ of vitamin D is required since bones 25

maternal bones and it enhances absorption of both - Ca fortified foods such as orange teeth calcium and phosphorous juice - Current research is : - Vitamin D sources: fortified Demonstrating an association milk, margarine, egg yolk, butter, between adequate calcium liver, seafood intake and the prevention of pregnancy induce hypertension Iron 30 mg/day representing a doubling Essential for of the pregnant daily requirement - Expansion of blood - Begin supplementation at 30Iron increases should reflect volume and red blood mg/day in second trimester, - liver, red meat, fish, poultry, cells formation since diet alone is unable to eggs - Establishment of fetal iron meet pregnancy requirement - enriched, whole grain cereals stores for first few months - 60 – 120 mg/day along with and breads of life copper and zinc - dark green leafy vegetables, supplementation for women legumes who have low hemoglobin - nuts, dried fruits values prior to pregnancy or - vitamin C sources: citrus fruits who have iron deficiency & juices, strawberries, anemia. cantaloupe, broccoli or - 70 mg/day of vitamin C which cabbage, potatoes enhances iron absorption - iron from food sources is more - inadequate iron intake results in readily absorbed when served maternal effects – anemia with foods high in Vitamin C depletion of iron stores, decreased energy and appetite, cardiac stress especially labor and birth - fetal effects decreased availability of oxygen thereby affecting fetal growth * iron deficiency anemia is the most common nutritional disorder of pregnancy. Zinc 15 mcg/day representing an increase Zinc increases should reflect Essential for of 3 mg/day over pre-pregnant daily - liver, meats * the formation of enzymes requirements. - shell fish * may be important in the - eggs, milk, cheese prevention of congenital - whole grains, legumes, nuts malformation of the fetus. Folic Acid, Folacin, Folate 400 mcg/day representing an Increases should reflect Essential for increase of more then 2 times the - liver, kidney, lean beef, veal - formation of red blood daily pre-pregnant requirement. - dark green leafy vegetables, cells and prevention of 300mcg/day supplement for women broccoli, legumes. anemia with low folate levels or dietary - Whole grains, peanuts - DNA synthesis and cell deficiency formation; may play a 4 servings of grains/day role in the prevention of neutral tube defects (spina bifida), abortion, 26

abruption placenta Additional Requirements Minerals - iodine - Magnesium - Selenium Vitamins E Thiamine Riboflavin Pyridoxine ( B6) B12 Niacin

175 mcg/day 320 mg/day 65 mcg/day

Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy. Vitamin stored in body. Taking it not needed – fat soluble vitamins. Hard to excrete.

10 mg/day 1.5 mg/day 1.6 mg/day 2.2 mg/day 2.2 mg day 17 mg/day

Vitamin A,D,E,K - - - No need to take it daily ( FAT SOLUBLE ) 2. Sexual Activity a.) b.) c.) d.) e.) f.) should be done in moderation should be done in private place that the mother should be placed in comfortable position; sidelying or mother on top it must be avoided 6 weeks prior to Expected Date of Delivery avoid blowing or air during cunnilingus to prevent air embolism changes in sexual desire of mom during pregnancy a.) 1st trimester – decrease desire – due to bodily changes b.) 2nd trimester – increased desire due to increase estrogen that enhances lubrication c.) 3rd trimester – decreased desire – due to bodily changes

Contraindication in sex: 1. vaginal spotting 1st trimester – threatened abortion 2nd trimester – placenta previa 2. incompetent cervix 3. preterm labor 4. premature rupture of membrane – prone to infection 3. Exercise – to strengthen muscles that will be used during delivery process - it must be done in moderation principles of exercise - it must be individualized – case to case basis * Walking – best exercise * Squatting – strengthen muscles of perineum and increase circulation to perineum. Done feet flat on floor * Tailor Sitting – same with squatting – done by placing one leg in front of other leg ( Indian seat) Raise buttocks 1st before head to prevent postural hypotension – dizziness when changing position * Shoulder Circling Exercise – to strengthen chest muscles * Pelvic Rocking/Pelvic Tilt Exercise – to relieve low back pain & maintain good posture - can be used to Lordosis * Arch Back – standing or kneeling. Four extremities on floor 27

* Kegel Exercise – to strengthen pubococcygeal muscles - as if hold urine, release 10x or muscle contraction * Abdominal Exercise – to strengthen the muscles of the abdomen – done as if blowing candle

4. Childbirth Preparation: Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience. a. Psychophysical 1. Bradley Method – discovered by Dr. Robert Bradley , advocated active participation of husband during delivery process to serve as a coach. Based on imitation of nature. Features: 1.) darkened room 2.) quiet environment 3.) relaxation tech 4.) closed eye & appearance of sleep 2. Grantly Dick Read Method – that fear leads to tension while tension leads to pain - to remove fear by relaxation technique and abdominal exercises b. Psychosexual 1. Kitzinger Method – discovered by Dr. Shiela Kitzinger , that pregnancy, labor, birth & the care of the newborn is an important turning point in a woman’s life cycle - for a mother to achieve the satisfying childbirth experiences, flow with contraction rather than struggling with contraction c. Psychoprophylaxis – prevention of pain 1. Lamaze – discovered by Dr. Ferdinand Lamaze - prevention of pain in the brain Features: discipline, conditioning & concentration with the help of the Husband 1. Conscious relaxation 2. Cleansing breathe – inhaling through the nose and exhaling through the mouth 3. Effleurage – gentle circular massage over abdomen to relieve pain 4. Imaging – sensate focus 5. Different Methods of delivery: 1.) Birthing Chair – bed convertible to chair – “semifowlers” position 2.) Birthing Bed – “dorsal recumbent” position 3.) Squatting Position – position that facilitates descent and relieves low back pain during labor pain 4.) Leboyers Method – features: warm, quiet, darkened room, calm and comfortable environment, room temperature, soft music. - After delivery, baby gets warm bath. 5.) Birth Under Water – warm water in a bathtub – labor & delivery – warm water, soft music. - After delivery the baby should be kept warmth, prepare for bathing IX. Intrapartal Notes – inside Emergency Room 28

A.

Admitting the laboring Mother: * Personal Data: name, age, address, etc * Baseline Data: v/s especially BP, weight * Obstetrical Data: gravida # pregnancy, para- viable pregnancy – 22 – 24 weeks * Physical Examination * Pelvic Examination Basic knowledge in Intrapartum. b. 1 Theories of the Onset of Labor 1.) Uterine Stretch Theory - any hollow organ once stretched to its maximum potential will always contract & expel its content – contraction action 2.) Oxytocin Theory – posterior pituitary gland releases oxytocin that produce by hypothalamus. 3.) Prostaglandin Theory – stimulation of Arachidonic Acid which causes contraction to the onset of labor. – prostaglandin “male” 4.) Progesterone Theory – before labor, decrease progesterone will stimulate contractions and labor 5.) Theory of Aging Placenta – lifespan of placenta is 42 weeks. By 36 weeks the placenta is beginning to degenerate hence causes the uterus to contract to the onset of labor. b.2. The 4 P’s of Labor

B.

1. Passenger - FETUS a. Fetal head – is the largest and common presenting part comprises of ¼ of its length. Bones – 6 fetal bones ( in all = 8 bones ) S – sphenoid F – frontal - sinciput E – ethmoid O – occuputal - occiput T – temporal P – parietal 2 x Important Measurement fetal head: 1. Transverse Diameter Biparietal – largest transverse – 9.25cm Bitemporal - 8 cm Bimastoid - 7cm smallest transverse 2. Anterior Posterior Diameter (AP ) Suboccipitobregmatic – from occiput to bregmatic ( smallest AP diameter) - complete flexion Occipito Frontal – 12 cm partial flexion Occipito Mental – 13.5 cm hyperflexion ( largest AP ) Submentobregmatic ( face presentation ) Sutures – intermembranous spaces that allow molding. a) Sagittal Suture – connects 2 parietal bones ( sagitna ) b) Coronal Suture – connect parietal & frontal bone ( crown ) c) Lambdoidal Suture – connects occipital & parietal bone Moldings: the overlapping of the sutures of the skull to permit passage of the 29

head to the pelvis Fontanels: 1.) Anterior fontanel – “bregma”, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), Closes – 12 – 18 months after birth 2.) Posterior fontanel – “lambda” – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.

2. Passageway – Vagina / Pelvis Candidate for C/S =

1.) Below 4’9” tall 2.) Below 18 years old – pelvic not yet achieve fully 3.) Underwent cephalo pelvic dislocation

a. Pelvis 4 main pelvic types 1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy 2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow 3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow 4. Platypelloid – flat AP diameter – narrow, transverse – wider b. Bones of Pelvis 2 hip bones – 2 innominate bones 3 Parts of 2 Innominate Bones Ileum – lateral side of hips * iliac crest – flaring superior border forming prominence of hips Ischium – inferior portion *ischial tuberosity – areas where we sit , the basis in getting external measurement of pelvis Pubes in the anterior portion *symphysis pubis - junction between 2 pubis 1 sacrum – posterior portion *sacral prominence – basis for internal measurement of pelvis 1 coccyx – composed of 5 small bones compresses during vaginal delivery Important Measurements: 1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis pubis. Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm = true conjugate) 2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm 3. Obstetrical conjugate – smallest AP diameter. Pelvis measuring at 10 cm or more. 4. Tuberoischi Diameter – transverse diameter of the pelvic outlet. *Ischial tuberosity – approximated with use of fist – 8 cm & above. 3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor a. Involuntary Contractions 30

b. Voluntary bearing down efforts c. Characteristics: wave like d. Timing: frequency, duration, intensity e. Support System

4. Psyche/Person – (mother) psychological stress exist when the mother is fighting the labor experience ( effective pushing ) a. Cultural Interpretation b. Preparation c. Past Experience d. Support System b.3 Pre-eminent Signs of Labor 1. Lightening – settling of presenting part into pelvic ring - 2 weeks prior to EDD Signs &Symptoms: - shooting pain radiating to the legs - urinary frequency (plexus/bladder) - pressure at the lumbo sacral nerve * Engagement- settling of presenting part of the fetus far enough into the pelvis to be at the level of ischial spine, a midpoint of the pelvis. 2. Braxton Hicks Contractions – painless irregular contractions 3. Increase Activity of the Mother- “nesting instinct” (due to epinephrine). Let the mother reserve the energy, will be used for delivery. 4. Ripening of the Cervix – comparable to butter softness 5. decreased body weight – 1.5 – 3 lbs 6. Bloody Show – pinkish vaginal discharge ( combinatiuon of blood & leukorrhea ) 7. Rupture of Membranes – rupture of water bag. Check Fetal Heart Tone PROBLEMS: Premature Rupture of Membrane ( PROM) - do Internal Examination to check for cord prolapse * Contraction drop in intensity even though very painful * Contraction drop in frequently * Uterus tense and/or contracting between contractions * Abdominal palpations Nursing Care: * Administer Analgesics (Morphine) * Attempt manual rotation for ROP or LOP – most common mal position * Bear down with contractions * Adequate hydration – prepare for Cesarean Section * Sedation as ordered * Cesarean delivery may be required, especially if fetal distress is noted NOTE: Do internal examination when the umbilical cord falls or is washed through the cervix into the vagina. 31

Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix into the vagina. Danger signs: * PROM * Presenting part has not yet engaged * Fetal distress * Protruding cord form vagina Nursing care: 1. Slip cord away from presenting part 2. Count pulsation of cord for Fetal Heart Tone 3. Positioning – trendelenberg or knee chest position 4. Observe for fetal distress 5. provide emotional support 6. Prepare mother for Cesarean Section • Cover cord with sterile gauze with saline solution - to prevent drying of cord so cord will remain slippery. * NOTE: five minutes cord compression can lead to irreversible brain damage such as cerebral palsy. b.4. Difference Between True Labor and False Labor False Labor True Labor * Irregular contractions * Contractions are regular * No increase in intensity * Increased intensity * Pain – confined on abdomen * Pain – begins lower back radiates to abdomen * Pain – relived by walking * Pain – intensified by walking * No cervical changes * Cervical effacement & dilatation - major symptom of true labor. Effacement – softening & thinning of cervix. Use % in unit of measurement Dilatation – widening of cervix. Unit used is cm. b.5 Duration of Labor Primipara – 14 hours not more than 20 hours Multipara – 8 hours not more than 14 hours b.6 Nursing Interventions in Each Stage of Labor 2 segments of the uterus 1. upper uterine - fundus 2. lower uterine – isthmus 1. First Stage: onset of true contractions to full dilation and effacement of cervix. Latent Phase: ( The mother is excited but apprehensive and can communicate) Assessment: Dilatations: 0 – 3 cm Frequency: every 5 – 10 min 32

Intensity : mild Nursing Care: 1. Encourage walking - to shorten the 1st stage of labor 2. Encourage to void every 2 – 3 hours – full bladder inhibit uterine contractions 3. Breathing – chest breathing Active Phase: ( Mother feels losing control of herself ) Assessment: Dilatations: 4 - 8 cm Intensity: moderate Frequency : every 3 - 5 minutes lasting for 30 – 60 seconds Nursing Care: M – medications – have medicines ready A – assessment include: vital signs, cervical dilatation and effacement, fetal monitoring, etc. D – dry lips – oral care (ointment) - dry linens, change the wet linen B – abdominal breathing Transitional Phase: ( the mood of the mother suddenly change accompanied by hyperesthesia – hypersensitivity to touch ) Assessment: Dilatations: 8 – 10 cm Frequency : every 2 - 3 minutes contractions Durations : 45 – 90 seconds Intensity: Strong Hyperesthesia – increase sensitivity to touch, pain all over Nursing Care: T – tires I – inform of progress- best way to give emotional support to the mother R – restless, support her to do breathing technique (chest breathing) E – encourage and praise D – discomfort – due to sacral pressure Health Teaching : * teach the father about sacral pressure technique on lower back to inhibit transmission of pain * keep informed of progress * controlled chest breathing Contractions: Increment/ Crescendo – beginning of contraction until it increases Acme/ Apex – height of contraction Decrement/ Decresendo – from height of contraction until it decreases * Pelvic Exams Effacement: – softening & thinning of cervix. Dilatation: - widening of cervix. a. Station – relationship of the presenting part to the ischial spine landmark used: ischial spine Floating – negative station - 1 station = presenting part 1cm above ischial spine if (-) floating - 2 station = presenting part 2 cm above ischial spine if (-) floating 33

- 0 station = level at ischial spine – engagement + 1 station = below 1 cm ischial spine +3 ,+4, +5 = crowning – occurs at 2nd stage of labor

b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother - spine of mom and spine of fetus Two types: b.1. Longitudinal Lie ( Parallel) Cephalic - Vertex – when the fetus is completely flex Face Brow Poor Flexion Chin Breech - Complete Breech – thigh rest on abdomen, while leg rest on thigh Incomplete Breech Frank – thigh rest on abdomen while leg rest on the head Footling – presenting part – foot : single, double Kneeling – presenting part - knees b.2. Transverse Lie (Perpendicular) or Perpendicular lie. - Shoulder presentation is very rare – 1 % c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis. Variety: Occipito/ Occiput LOA left occipito anterior (most common and favorable position) – side of maternal pelvis LOP – left occipito posterior LOP – most common mal position, most painful ROP – squatting pos on mom ROT ROA A – Anterior L – Left – side of maternal pelvis O – Occipito – denominator ROP; LOP : most painful position; best – squatting position LOA – most favorable position FACE – Mentum LMA, LMT, LMP, RMA, RMT, RMP Shoulder – Acromio Dorso – LADA, LADT, LADP, RADA, RADT, RADP Breech- SACRO - LSA – left sacro anterior LST, LSP, RSA, RST, RSP Shoulder/acromniodorso: LADA, LADT, LADP, RADP Chin / Mento: LMA, LMT, LMP, RMP, RMA, RMT, RMP • In cases of breech presentation –place the stethoscope above the umbilicus Sign of fetal distress: 34

• • •

< 120 or > 160 bpm meconium stain fetal trushing – hyperactivity of fetus due to lack of oxygen.

Monitoring the Contractions and Fetal heart Tone Spread fingers lightly over fundus – to monitor contractions Parts of contractions: Increment or crescendo – beginning of contractions until in increases Acme or apex – height of contraction Decrement or decrescendo – from height of contractions until it decreases Duration – beginning of contractions to end of same contraction Interval – from the end of 1 contraction to beginning of next contraction Frequency – beginning of 1 contraction to beginning of next contraction Intensity – the strength of contraction Once contraction occur, the blood vessel will constrict – vasoconstriction – decrease the oxygen/circulation hence, maternal BP increases - Increase BP – while Fetal Heart Tone decreases. What will happen to the fetus? = The fetus has placental reserve for 60 seconds Best time to get BP of the mother = just after the contraction Best time to get FHT = midway of contraction Placental reserve = 60 seconds for fetus during contractions Duration of contractions shouldn’t > 60 sec Notify MD Health Teachings: • Mom has Headache – check BP, if same BP, let mom rest. If BP increases, notify MD – preeclampsia • Hungry mother – NPO - no meals GI is not functioning thus to prevent aspiration • Bathe – mother can bathe after the delivery • Enema – optimum rectal tube – 12 - 18 inches a.) To cleanse bowel b.) Prevent infection c.) Sims position/side lying Constipated mother – slowly pulling the rectal tube * During insertion of rectal tube – contraction – clamp – after insertion – check the FHT after administration of enema Normal FHT = 120-160 bpm * Perineal Preparation – method ( 7 method ) • Position : Left lateral position – to prevent supine hypotension or the supine vena caval syndrome. 35

Pain during labor – can give Meperidine HCL ( Demerol ) – narcotic antispasmodic ( during active phase 6 – 8 cm ) Toxic Effect: respiratory depression Antidote : Narcan ( Naloxone ) Note: Amniotomy – artificial rupture of the membrane Respiratory Alkalosis – signs and symptoms ( increase RR, Tingling sensation, light headedness,

2. Second Stage: fetal stage, complete dilation and effacement to birth. The mother will be transferre to the delivery room when: 7 – 8 cm for the multi – bring to delivery room 8 – 10 cm for the primi (fully dilated) – bring to delivery room Position: Lithotomy by placing the mother’s legs at the same time up Bulging of perineum – sure to come out Breathing – panting ( teach mother) Assist the doctor in doing episiotomy- to prevent laceration - widen vaginal canal - shorten 2nd stage of labor. Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula) Mediolateral – more bleeding & pain, hard to repair, slow to heal - use local or pudendal anesthesia. Ironing the perineum – to prevent laceration Modified Ritgens maneuver – place towel at perineum 1.) To prevent laceration 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby. Mechanisms of labor 1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External rotation 7. Expulsion Three parts of Pelvis 1. Inlet – AP diameter narrow, transverse diameter wider 2. Cavity – area of inlet and outlet 3. Outlet – AP wider, transverse narrow Two Major Divisions of Pelvis 1. True pelvis – below the pelvic inlet 2. False pelvis – above the pelvic inlet; supports uterus during pregnancy * Linea Terminales - diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis. 36

* Episiotomy – is a surgical incision of the perineum in order to prevent laceration; to widen the vaginal canal; to shorten the second stage of labor. Two Types of episiotomy: 1. Midline – incise the midline of the perineum Advantage: Easy to repair, fast healing, less blood loss, less postpartum discomfort Disadvantage: incision may extend to anus that leads to urethroanal fistula ( use sometimes )

2. Mediolateral – incision is made beginning to the midline but directed laterally away from the rectum. Advantage: less danger of complication from rectal mucosal tear Disadvantage: more bleeding (more blood vessels hit), hard to repair, slow healing, more discomfort Note: Once the head is crowning – ironing the perineum (to prevent laceration) Modified Ritgens Maneuver – support the perineum (prevent laceration) Once the head is out – support the head and remove secretions, check the cord by inserting 2 fingers. Nursing Care: • Note the time of delivery • Placing the baby below the vulva • Place un dependent part • Place in the abdomen of the mother – for bonding and the weight of the baby facilitates the contraction of the uterus • Clamp the baby’s cord – wait for pulsation to stop before clamping the cord since 60 – 100 cc of blood will be going to baby. • Proper identification, footprinting • If in case the baby is dead, show the baby to the mother for acceptance of the finality of dead. • To prevent puerperal sepsis - < 48 hours only – vaginal pack Note: Bolus of Ptocin can lead to hypotension. 3. Third Stage: birth to expulsion of Placenta - placental stage The Placenta should be expelled 3-10 minutes after the delivery of the baby Signs of placental separation 1. Fundus rises – becomes firm & globular “ Calkins sign” if not – Uterine Atony 2. Lengthening of the cord – Brandt Andrew’s maneuver – slowly pulling of the cord 3. Sudden gush of blood Types of placental delivery • Shultz “shiny” – begins to separate from center to edges presenting the fetal side – shiny • Dunkan “dirty” – begins to separate form edges to center presenting maternal side – beefy red or dirty Note: Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. 37

Nursing care for placenta: • Check completeness of placenta.- placenta has 15 – 28 cotyledons • Check fundus (if relaxed, massage uterus – if not firm) • Check blood pressure - Administer Methergine IM (Methylergonovine Maleate) as ordered. It should be given IM, check the BP before administration. “Ergotrate derivatives. • Monitor hypertension (or give oxytocin IV) • Check perineum for lacerations • Assist MD in doing episiorapy , vaginal pack should be used for 48 hours to prevent puerperal sepsis. • In recovery room, should be Flat on bed • If chilling occurs – due to dehydration – just give additional Blanket • Give clear liquid – ( tea, ginger ale, clear gelatin, Gatorade) – once regulated, can be given full liquid such as milk, ice cream, soup then soft diet to regular diet. • Let mother sleep to regain energy. 4. Fourth Stage: the first 1 - 2 hours after delivery of placenta – recovery stage. a. Maternal Observations – body system stabilizes Check the vital signs q 15 for 1 hour. 2nd hour q 30 minutes. b. Placement of the Fundus – just above the umbilicus or level of umbilicus. If palpated on the right side – it means full bladder therefore – empty the bladder. If fundus above umbilicus, deviation of fundus 1.) Empty bladder to prevent uterine atony 2.) Check lochia c. Lochia – vaginal discharges after the delivery process Rubra – red, 1 - 3 days moderate Serosa – pink to brown, 4 – 9 days , decrease in amount, with musty odor Alba – creamy white, 10 days – 3 weeks d. Perineum – check the perineum for : R - redness E- edema E - ecchymosis D – discharges A – approximation of blood loss. * Count pad & saturation * Fully soaked pad : 30 – 40 cc weigh pad. 1 gram = 1cc e. Bonding – interaction between mother and newborn Types of rooming: 1.) Strict rooming: 24 hours - baby stays with mother. 2.) Partial rooming in: baby stays with mother in the morning and stays in the nursery at night . Complications of Labor • Dystocia – difficult labor related to mechanical factor – due to uterine inertia which means sluggishness of contraction 2 Types of uterine inertia: 1.) hypertonic or primary uterine inertia - intense excessive contractions resulting to ineffective pushing Management: sedation – MD administer sedative Valium/Diazepam – muscle relaxant 2.) hypotonic – secondary uterine inertia, slow irregular contraction 38

resulting to ineffective pushing. Management: Administer Oxytocin Prolonged labor – resulting to: Maternal Effect: exhaustion ( overpushing ) Fetal Effect: fetal distress, cephalohematoma or caput succedaneum  20 hours – Primi  14 hours – Multi * normal length of labor in primi 14 – 20 hours ; Multi 10 - 14 hours Management: Check and monitor Contraction and Fetal Heart Tone

Precipitate Labor - labor of < 3 hours. extensive lacerations to mother that leads to profuse bleeding → hypovolemic shock → hypotension, Tachypnea, Tachycardia, cold clammy skin Note: Earliest sign: tachycardia & restlessness Late sign: hypotension Outstanding Nursing diagnosis: fluid volume deficit Position of mother: Modified Trendelenberg IV – fast drip due fluid volume deficit Signs of Hypovolemic Shock: Hypotension Tachycardia Tachypnea Cold clammy skin

Inversion of the Uterus – uterus is turned inside out due to the following factors: a. hurrying pull out of the placenta b. ineffective fundal pressure c. short cord Management: MD will push uterus back inside or not hysterectomy. • Uterine Rupture – Possible causes: 1.) Previous classical Cesarean Section 2.) Large baby 3.) Improper use of oxytocin (IV drip) Symptoms: a.) sudden pain b.) profuse bleeding c.) hypovolemic shock d.) TAHBSO Note: Physiologic Retraction – boundary between upper and lower uterine segment Suprapubic Depression – sign of impending rupture of the uterus Bandl’s Pathologic Ring – bleeding that leads to hypovolemic to TABHBSO • Amniotic Fluid Embolism – a situation of amniotic fluid or fragments of placenta enters natural circulation resulting to embolism. If NSD – Signs and Symptoms: a. dyspnea b. chest pain 39

c. frothy sputum Prepare: suctioning end stage: DIC disseminated intravascular coagopathy * intravascular coagopathy - bleeding to all portions of the body such as eyes, nose, etc. • Trial Labor – when the head measurement and pelvis measurement falls on the borderline. Management: Give the mother 6 hours of labor allowance: Multi: 8 – 14; primi : 14 – 20 Monitor Fetal Heart Tone and Contraction

Pre Term Labor – labor after 24 weeks before the 37th week Triad of Preterm Symptoms: 1. Premature contractions every 10 minutes 2. Effacement of 60 – 80 % 3. Dilatation of 2 - 3 cm Home Management: 1. complete bed rest 2. avoid sex 3. empty bladder 4. drink 3 - 4 glasses of water – full bladder inhibits contractions 5. consult MD if symptoms persist Hospital Management: 1. If cervix is closed (2 – 3 cm), dilation saved by administer Tocolytic agents- to halts the preterm contractions of the uterus. (YUTOPAR - Yutopar Hcl) 150 mg incorporated 500 cc Dextrose piggyback. Monitor: FHT > 180 bpm Maternal BP - < 90/60 Crackles – notify MD Pulmonary edema – administer oral yutopar 30 minutes before d/c IV PreTerm: Magnesium Sulfate • Before delivery mother will be given : DEXAMETHASONE –to facilitate surfactant maturation. • Tocolytic (Phil) • Terbuthaline (Bricanyl or Brethine) – sustained tachycardia • Antidote – propranolol or inderal - beta-blocker Note : * If cervix is open – MD – steroid dexamethsone (betamethazone) to facilitate surfactant maturation preventing Respiratory Distress Syndrome * Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia. * Term – suction at once X. Postpartal Period 5th stage of labor after 24hours: Normal increase WBC up to 30,000 mm3 Puerperium – covers 1st 6 wks post partum Involution – return of reproductive organ to its non pregnant or normal state. Hyperfibrinogenia - prone to thrombus formation 40

- early ambulation

Principles Underlying Puerperium I. To return to Normal and Facilitate Healing A. Physiologic Changes a.1. Systemic Changes 1. Cardiovascular System The first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers.( 1st one hour after delivery – monitor the vital signs every 15 minutes ) Increase of temperature on the 1st 24 hours is normal. Increase in WBC (30,000mm3 ) immediately after delivery results to Hyperfibrogenemia. To prevent Thromboplebitis – encourage early ambulation, sometimes, may experience Postural Hypotension – gradually position the patient from semi to high fowlers a.2. Genital Tract a. Cervix – cervical opening b. Vaginal and Pelvic Floor c. Uterus – return to normal 6 – 8 weeks. Fundus goes down 1 finger breath/day until 10th day – no longer palpable due behind symphysis pubis 3 days after post partum: subinvolution uterus – delayed healing uterus containing big, quarters or deep clots of blood - a medium for bacterial growth - (puerperal sepsis) Management: Dilatation & Curettage After - birth pain : 1. position prone 2. cold compress – to prevent bleeding 3. mefenamic acid d. Lochia - bld, wbc, deciduas, microorganism. NSD & C/S with lochia. 1. Ruba – red 1st 3 days present, musty/mousy, moderate amount 2. Serosa – pink to brown 4 – 9th day, limited amount 3. Alba – creamy white 10 – 21 days very decreased amount a.3. Urinary tract: Bladder Frequency in urination after delivery (postpartum) - urinary retention with overflow Dysuria – trigone of bladder Nursing Action: - urine collection - alternate warm & cold compress - stimulate bladder Colon: Constipation – due to NPO, fear of bearing down; episiotomy 41

Perineal area: – painful – episiotomy site Position: Sim’s position • Cold compress for immediate pain after 24 hours, • Hot sitz bath, Hot compress for immediate pain after 24 hours Sex Act - when perineum has healed

II. Provide Emotional Support – Reva Rubia 1. Psychological Responses: a. Taking in phase – dependent phase (1st three days) mother – passive, cannot make decisions, activity is to tell childbirth experiences. Nursing Care: - proper hygiene b. Taking hold phase – dependent to independent phase (4 to 7 days). Mother is active, can make decisions Focus: 1. Care of newborn 2. Insert family planting method Note: common post partum blues/ baby blues present 4 – 5 days 50 - 80 % moms – overwhelming feeling of depression characterized by crying, despondence inability to sleep & lack of appetite. let mom cry, it is therapeutic. c. Letting go – interdependent phase – 7 days & above. Mother - redefines new roles may extend until child grows. III. Prevent complications 1. Hemorrhage – bleeding of > 500cc CS – 600 – 800 cc normal NSD - 500 cc I. Early postpartum hemorrhage – bleeding within 1st 24 hours. a. Uterine Atony - Boggy or relaxed uterus & profuse bleeding Complications: hypovolemic shock. Position: Modified Trendelenberg Management: 1.) massage uterus until contracted 2.) cold compress 3.) modified trendelenberg 4.) IV fast drip/ oxytocin IV drip as ordered Note: * If no effect after massage → cold compress → position → then let the newborn suck the mother’s breast in order to stimulate the pituitary to release oxytocin for the contraction of the uterus. * Breast feeding – posterior pituitary gland will release oxytocin so will contract. * Well contracted uterus + bleeding = laceration 42

uterus

b. Laceration - Contracted uterus but with profuse bleeding Nursing Action: assess episiotomy assess perineum for laceration degree of laceration Management: Episiorapy 1st degree laceration – affects vaginal skin & mucus membrane. 2nd degree – 1st degree + muscles of vagina 3rd degree – 2nd degree + external sphincter of rectum 4th degree – 3rd degree + mucus membrane of rectum

c. Hematoma - bluish / purplish discoloration of subcutaneous vagina or Perineum. May be due to : too much manipulation large baby pudendal anesthesia Management: * Cold compress every 30 minutes with rest period of 30 minutes repeat for 24 hours * Shave * Incision on site, scraping & suturing DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen - failure to coagulate bleeding to any part of body Note: hysterectomy if with abruption placenta Management: Blood Transfusion , cryoprecipitate or fresh frozen plasma II. Late Postpartum hemorrhage – bleeding after 24 hours 1. Retained Placental Fragments Management: Dilatation & Curettage or manual extraction of fragments & massaging of uterus : Except: * Placenta Accreta - unusual attachment to myometrium * Placenta Increta - deeper attachment of placenta to myometrium * Placenta Percreta – invasion of placenta to perimetrium 2. Infection- sources of infection 1.) endogenous – from within body 2.) exogenous – from outside General signs: 1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling) and loss of function. anaerobic streptococci – most common: 1. from members health team 2. break in the chain of infection 3. unhealthy sexual practice 4. purulent discharges 5. fever General Management: Supportive Care: Complete Bed Rest , hydration/ fluid intake, TSB, cold compress, paracetamol, VITC, culture & sensitivity – before taking antibiotic * prolonged use of antibiotic lead to fungal infection 43

Infection of Perineum : 2 to 3 stitches dislodged with purulent discharge coming out Management: Removal of sutures & drainage Endometritis – inflammation of endometrial lining Signs of infection plus abdominal tenderness Position : Fowlers to facilitate drainage Administration of oxytocin as ordered Antibiotic – if not treated – lead to thrombophlebitis

IV. Motivate the use of Family Planning 1.) determine one’s own 1ST beliefs 2.) never advice a permanent method of family planning 3.) method of choice is an individuals choice/ own decision. 4.) Informed consent Natural Method – the only method accepted by the Catholic Church • Billings / Cervical mucus – test spinnbarkeit (estrogen) clear, watery, stretchable, elastic – long spinnbarkeit ferning – microscopic fern pattern Basal Body Temperature – due to progesterone 13th day temp goes down before ovulation – no sex - get before arising in bed LAM - Lactation Amenorrhea Method - related to breast feeding Prolactin – hormone that inhibits menstruation/ovulation Bottle Feeding – the mother will menstruate after 2 – 3 months Breastfeeding – the mother will menstruate after 4 - 6 months Disadvantage : might get pregnant Symptothermal – combination of BBT & cervical. Best method

Social Method: o coitus interuptus/ withdrawal - least effective method o coitus reservatus – sex without ejaculation ; common to callboy/callgirl o coitus interfemora – “ipit” o calendar method – 28 days cycle ( REGULAR ) OVULATION – count minus 14 days before next menstruation (14 days before next menstruation) Origoknause formula – IRREGULAR MENSTRUATION - get the longest and shortest cycle Shortest minus 18 an longest minus 11 – unsafe period REGULAR MENSTRUATION – 28 days minus 14 days plus 3 – 4 days before and after menstruation • monitor cycle for 1 year • get short test & longest cycle from January – December • shortest – 18 • longest – 11 44

June 26 Dec 33 - 18 -11 8 22 unsafe days th 21 day pill- start 5 day of menstruation 28 day pill- start 1st day of menstruation missed 1 pill – take 2 next day Physiologic Method  Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective.  Waiting time to become pregnant- 3 months.  Consult OB – 6 months. Alerts on Oral Contraceptive: • In case a mother who is taking an oral contraceptive for almost long time plans to have a baby, mother would wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal. • If a new oral contraceptive is prescribed the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses. • Discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage. Immediate Discontinuation A – abdominal pain C – chest pain H - headache E – eye problems S – severe leg cramps ACHES – signs of hypertension hence if the Blood Pressure of the mother is increased – stop the pills STAT! if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again. Adversed Effect: breakthrough bleeding Contraindicated:  chain smoker  extreme obesity  Hypertension  Diabetes Mellitus  Thrombophlebitis or problems in clotting factors

 DMPA – Depot Provera Medroxy Progesteron Acetate - depoproveda – has progesterone inhibits LH – inhibits ovulation Depomedroxy progesterone acetate – has progesterone inhibits LH – inhibits ovulation - IM every month - never massage injected site, it will shorten duration ( it can easily absorbed ) 45

 Norplant – has 6 matchsticks like capsule/rod dermally implanted containing progesterone. Note : 5 years – disadvantage if keloid skin as soon as removed – can become pregnant Mechanical and Chemical Barriers Intrauterine Device (IUD) Action: prevents implantation – affects motility of sperm & ovum - right time to insert is after delivery or during menstruation primary indication for the use f IUD: parity or # of children MULTIARITY if 1 child only don’t use IUD

Health Teaching: a. Check for string daily b. Monthly checkup c. Regular pap smear Alerts:  prevents implantation  inserted during menstruation and after delivery because the cervix is open  most common complications: excessive menstrual flow  most common problem: expulsion of the device  others complications – uterine infection uterine perforation and ectopic pregnancy Period late (pregnancy suspected) Abnormal spotting or bleeding Abdominal pain or pain with intercourse Infection (abnormal vaginal discharge) Not feeling well, fever, chills Strings lost, shorter or longer  Condom – made up of latex inserted to erected penis or lubricated vagina - it lessen sexual satisfaction - it gives higher protection in the prevention of STD’s Alert : female condom - give the most and highest protection against STD

 Diaphragm – made up of rubberized dome shaped material inserted to the cervix preventing sperm to get to the uterus. REVERSABLE Alert: 1.) proper hygiene should be observed since it is reusable 2.) check for holes before using it 3.) must be kept in place for about 6 – 8 hrs after sex 4.) must be refitted especially if weight change, ↑or ↓ by 15 lbs 5.) spermicide – chemical Barrier example: Foam (most effective), jellies, creams Side effect: Toxic shock syndrome  Cervical Cap – most durable than diaphragm - no need to apply spermicide - should be kept 24 hours, no need to reapply spermicides 46

Contraindication: abnormal pap smear  Foams, Jellies, Creams, Spermicidal agents – to kill spermicides Foam – most effective Spermicidal agents – toxic effect – Toxic Shock Syndrome Surgical Method  BTL ( Bilateral Tubal Ligation ) women ( tie, cut, cautery ) immediate sterilization – cut – can be reversed 20% chance. ( 20 – 30 reanastamosis ) - isthmus - is the site for sterilization Health Teaching : Avoid lifting heavy object

cut vas deferense. not immediate sterilization need to ejaculate 30 X for 0 sperm before considering a safe sex Health Teaching : > 30 ejaculations before safe sex O – zero sperm count, safe XI. High Risk Pregnancy 1. Hemorrhagic Disorders • To determine the integrity of sac • Prepare the mother for ultrasound • Save discharges for histopathology • Assess for complications like hypovolemic shock General Management 1.) Complete Bed Rest 2.) Avoid sex 3.) Assess for bleeding Fully saturated pad (per pad 30 – 40 cc) (weight – 1 gm =1 cc) 4.) Ultrasound to determine integrity of sac 5.) Signs of Hypovolemic shock 6.) Save discharges – for histopathology – to determine if product of conception has been expelled or not First Trimester Bleeding – abortion or eptopic A. Abortions – termination of pregnancy before age of viability (before 20 weeks) Age of viability – 20 - 24 weeks Intrauterine death or Stillbirth – after the age of viability 1. Spontaneous Abortion – also known as miscarriage Causes: 1.) chromosomal alterations 2.) blighted ovum 3.) plasma germ defect Classifications: a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed; can give progesterone 47

 Vasectomy ( men ) -

b. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation) cervix is open Types: b.1. Complete – all products of conception are expelled. Nursing Management: no need for D & C, just emotional support! b.2 Incomplete – Placenta and membranes retained. Management: for D& C b.3 Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2nd trimester

Incompetent cervix – abortion Surgery: a. McDonalds procedure – temporary circlage on cervix * During delivery, circlage is removed. NSD Side Effects: infection. b. Shirodkar – permanent surgery on cervix. CS b.4 Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) pregnancy test, scanty, dark brown bleeding Management: induced labor with oxytocin or vacuum extraction c. Induced Abortion – therapeutic abortion to save life of mother based on the principles of twofolds effect - choose between lesser evil. B. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity. Common site : tubal or ampular Dangerous site : interstitial Unruptured Tubal rupture

o missed period o abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided) o scant, dark brown, vaginal bleeding o vague discomfort

o sudden , sharp, severe pain. Unilateral radiating to shoulder. o shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve) o + Cullen’s Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding o syncope (fainting)

Nursing Care:

Surgery: 48

   

Vital Signs Administer IV fluids Monitor for vaginal bleeding Monitor I and O

* Fallopian - Salphingectomy * Abdominal - Exploratory Laparotomy * Uterus - Hysterectomy

Second trimester bleeding – small and incompetent cervix C. Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with fertilization. - Progressive degeneration of chorionic villi. Recurs. - Gestational anomaly of the placenta consisting of a bunch of clear vesicles. - This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. - The nucleus of the sperm duplicates, producing a diploid number 46 XX - It grows & enlarges the uterus vary rapidly. ( progressive degeneration of corionic villi ) Use: methotrexate to prevent choriocarcinoma Assessment: Early signs vesicles passed thru the vagina Hyperemesis gravidarium due to increase HCG Fundal height Vaginal bleeding ( scant or profuse) High levels of HCG Pre eclampsia at about 12 weeks

Early in pregnancy Late signs: -

hypertension before 20th week Vesicles look like a “ snowstorm” on sonogram Anemia Abdominal cramping hyperthyroidism Pulmonary embolus

Serious Late complications :

Nursing care: • Prepare for D & C • Do not give oxytoxic drugs – may cause embolism Teachings: a. Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma b. Avoid pregnancy for at least one year . Can have sex provided the partner will use condom for protection Third Trimester Bleeding “Placenta Anomalies” D. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. - Abnormal lower implantation of placenta. * candidate for CS Total – complete cover of the cervical os Partial – 5% Low 49

Assessment: Outstanding signs and symptoms:  FRANKBRIGHT RED PLEEDING, PAINLESS BLEEDING  Engagement (usually has not occurred)  Fetal distress  Presentation ( usually abnormal ) Complications:  Internal examination  Sudden fetal blood loss Diagnostic Examination:  Ultrasound Note: Avoid: sex, IE, enema – may lead to sudden fetal blood loss Double set up: delivery room may be converted to OR

Nursing Care:  NPO  Bed rest  Prepare to induce labor if cervix is ripe  Administer IV Note Alert : Surgeon – in charge of sign consent, RN as witness MD explain to patient E. Abruptio Placenta - it is the premature separation of the placenta form the implantation site. - It usually occurs after the twentieth week of pregnancy. • (due to use of cocaine ) – PIH Assessment:  dark red, painful bleeding  board like or rigid uterus/abdomen  Concealed bleeding/hemorrhage (retroplacental)  Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage.  Severe abdominal pain  Dropping coagulation factor (a potential for DIC) Complications:  Sudden fetal blood loss  placenta previa & vasa previa General Nursing Care:  Infuse IV, prepare to administer blood  Type and crossmatch  Monitor FHR  Insert Foley  Measure blood loss; count pads  Report signs and symptoms of DIC  Monitor v/s for shock  Strict I & O 50

F. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel which may lead to retained placental fragments if vessel is cut. G. Placenta Circumvalata – fetal side of placenta covered by chorion H. Placenta Marginata – fold side of chorion reaches just to the edge of placenta I. Battledore Placenta – cord inserted marginally rather then centrally J. Placenta Bipartita – placenta divides into 2 lobes K. Placenta Tripartita – placenta divides into 3 lobes L. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta M. Vasa Previa – velamentous insertion of cord has implanted in cervical OS

2. Hypertensive Disorders I. Pregnancy Induced Hypertension (PIH) • Hypertension after 24 wks of pregnancy, solved 6 weeks post partum. 1.) Gestational hypertension - HPN without edema & protenuria H without EP 2.) Pre-eclampsia – HPN with edema & protenuria or albuminuria HEP/A - idiopathic 3.) HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count - common in primi because of increase exposure to chronic villi - multiple pregnancy - Mother low socio-economic status - Increase sensitivity to Angiotensin II ↓ main effect peripheral vascular vasospasm ↓ decrease Oxygen supply → Hypertension ( main denominator ) ↓ KIDNEYS ↓ ↓ ↓

EYES Glomerular Degeneration Glomerular Filtration Placenta ↓ ↓ ↓ ↓ Retinal vassoconstriction increase permeability increase sodium absorption IUGR ↓ ↓ ↓ (intrauterine growth retardation) Blurred Vision proteinuria increase water retention ↓ SCOTOMA ↓

EDEMA ↓ ANASARCA


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↓ BLINDNESS LIVER – Tissue Ischemia ↓ Liver Edema ↓ Epigastric Pain ↓ BRAIN ↓ Cerebral Edema ↓ LUNGS ↓ Pulmonary Edema ↓ HEART ( CHF ) ↓ CONVULSION

PRE TERM LABOR

II. Transissional Hypertension – HPN between 20 – 24 weeks III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum. Three types of pre-eclampsia 1.) Mild preeclampsia – earliest sign of preeclampsia a.) increase wt due to edema b.) BP 140/90 c.) protenuria +1 - +2 2.) Severe preeclampsia Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110, protenuria +3 - +4 3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety. Cause of pre eclampsia 1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi 2.) common in multiple pre (twins) increase exposure to chorionic villi 3.) common to mom with low socioeconomic status due to decrease intake of CHON Nursing care: P – promote bed rest to decrease O2 demand, facilitate, sodium excretion, - water immersion will cause to urinate. P - prevent convulsions by nursing measures or seizure precaution 1.) maintain dimly lit room 2.) quiet calm environment 2.) minimal handling – planning procedure 3.) avoid jarring bed * Right Place of the patient: across the nursing station P- prepare the following at bedside - tongue depressor - side rail up before the seizure - turning to side done AFTER seizure (to facilitate drainage of secretion) 52

- prepare suction machine - Observe only! for safely. E – ensure high protein intake ( 1g/kg/day) - Na – in moderation (replace the protein loss) A – anti-hypertensive drug Hydralazine ( Apresoline) C – convulsion, prevention by : Mg S04 – CNS depressant or anti convulsant (absence of seizure) E – valuate physical parameters for Magnesium sulfate Magnesium SO4 Toxicity: 1. BP decrease 2. Urine output decrease 3. Resp < 12 4. Patella reflex absent – 1st sigh Mg SO4 toxicity. Antidote : Ca gluconate

3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas) Function of insulin: - facilitates transport of glucose to cell • glucose - energizer of cell • insulin – key for glucose Diagnostic Test: 1 hour 50 grams (glucose tolerance test ) GTT Normal glucose – 80 – 120 mg/dl ( euglycemia) < 80 – hypoclycemic > 120 - hyperglycemia 3 hours GTT of > 130 mg/dL Maternal Effect Diabetes Mellitus 1.) Hypo or hyperglycemia – 1st trimester hypo, 2nd – 3rd trim – hyperglycemic * hpl – serves as insulin antagonist 2.) Frequent infection- moniliasis/candidiasis 3.) Polyhydramnios 4.) Dystocia - difficult birth due to abnormalities in fetus or mother is big 5.) Insulin requirement, decrease in insulin by 33 % in 1st tri; 50 % increase insulin at 2nd – 3rd trimester. Post partum decrease 25% due placenta out. No more hormone (hpl) - given by shots, not oral because it is teratogenic Fetal effect 1.) hyper & hypoglycemia 2.) macrosomia – large for gestational age – baby delivered > 4000 g or 4 kg – largest 8000 g 3.) preterm birth to prevent stillbirth 4.) IUGR (Intrauterine Growth Retardation) Newborn Effect : Diabetes Mellitus 1.) hyperinsulinism 2.) hypoglycemia normal glucose in newborn 45 – 55 mg/dL 53

borderline – 40 mg/dL hypoglycemic < 40 mg/Dl * glucose – food for the brain Management: Heel stick test – get blood at heel - administer dextrose - monitor Signs and Symptoms: - Hypoglycemia - high pitch shrill cry - tremors 3.) hypocalcemia - < 7 mg% Signs and Symptoms: Calcemic tetany Trousseau sign

Management : Give calcium gluconate if decrease calcium Recommendation Therapeutic abortion If push through with pregnancy 1.) antibiotic therapy- to prevent sub acute bacterial endocarditis 2.) anticoagulant – heparin doesn’t cross placenta Class I & II- good prognosis for vaginal delivery Class III & IV- poor prognosis, for vaginal delivery, not CS! - general anesthesia - anti coagulant therapy – “Heparin” – if pregnant only - Antibiotic – to prevent subacute endocarditis NOT lithotomy! High semi-fowlers or sidelying position during delivery (best position) No valsalva maneuver Regional anesthesia! Caudal (anesthesia of choice) Low forcep delivery due to inability to push. It will shorten 2nd stage of labor. Heart disease Mothers with RHD at childhood Class I – no limitation of physical activity Class II – slight limitation of physical activity. - Ordinary activity causes fatigue & discomfort. Recommendation of class I & II 1.) sleep 10 hours a day 2.) rest 30 minutes & after meal Class III - moderate limitation of physical activity. - Ordinary activity causes discomfort and fatigue Recommendation: 1.) early hospitalization by 7 months Class IV. marked limitation of physical activity for even at rest there is fatigue & discomfort. Recommendation: Therapeutic abortion XII. Intrapartal complications 54

1. Cesarean Delivery a. b. c. d. e. f. g. h. i. j.

Indications: Multiple gestation Diabetes Active herpes II Severe toxemia Placenta previa Abruptio placenta Prolapse of the cord CPD primary indication Breech presentation Transverse lie

Procedure: a. Classical – vertical insertion. Once classical always classical b. Low segment – bikini line type – “aesthetic use” - transverse VBAC – vaginal birth after CS – low segment

INFERTILITY - inability to achieve pregnancy. Within a year of attempting it • Manageable STERILITY • irreversible Impotency – inability to have an erection 2 types of infertility 1.) Primary – no pregnancy at all 2.) Secondary – 1st pregnancy, no more next pregnancy Test Male 1st o more practical & less complicated o need: sperm only o sterile bottle container ( not plastic has chem.) o Sims Huhner test – or post coital test. Procedure: sex 2 hours before test mother – remains supine 15 minutes after ejaculation Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If > 15 – low sperm count Best criteria - sperm motility for impotency Factors: low sperm count 1.) Occupation - truck driver 2.) chain smoker Administer: clomid ( chomephine citrate) to induce spermatogenesis ↓ if not effective Management: GIFT = “Gamete Intra Fallopian Transfer” for low sperm count Implant sperm in ampula 1.) Mom: anovulation – no ovulation. Due to increase prolactin – hyperprolactinemia ( inhibit ovulation ) Administer: parlodel ( Bromocryptice Mesylate) Action: antihyper prolactineuria (antiparkinsonian) Give mom clomid: action: to induce oogenesis or ovulation 55

Side Effects: multiple pregnancy 2.) Tubal Occlusion – tubal blockage – o History of PID that has scarred tubes o Use of IUD (peritonitis) o Appendicitis (burst) & scarring Diagnostic Test: hysterosalphingography – used to determine tubal patency with use of radiopaque material Management: IVF – invitrofertilization (test tube baby) England 1st test tube baby To shorten 2nd stage of labor: 1.) fundal pressure 2.) episiotomy 3.) forcep delivery

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