MATERNITY NURSING

I. HUMAN SEXUALITY

A. Concepts

1. A person‘s sexuality encompasses the complex behaviors, attitudes emotions & preferences that are related
to sexual self & eroticism.
2. Sex – basic & 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 *Gender Identity : 3 y/o or 2-4 y/o

*Role identity -attitudes, behaviors & 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/ woman & is an entity
subject to a life long dynamic change. Developed at the moment of
conception.

II. SEXUAL ANATOMY & PHYSIOLOGY

A. Female Reproductive System

1. External Genitalia : ―Vulva or Pudenda‖

a. Mons Pubis/Veneris or “ Mountain of Venus”

- a pad of fatty tissues that lies over the symphysis pubis covered by skin & at puberty covered by
pubic hair that serves as cushion or protection to the symphysis pubis.

Stages of Pubic Hair Development

Tool Used: Tanner‘ Scale---used to determine sexual maturity rating.

Stage 1 – Pre-adolescence > No pubic hair. Fine body hair only

Stage 2 – Occurs between ages 11 & 12 – sparse, long, slightly pigmented

& curly hair develops along labia
Stage 3 occurs between ages 12 & 13 – darker & curlier along pubic symphysis

Stage 4 – occurs between ages 13 & 14, hair assumes the normal appearance of an adult but is
not so thick & does no appear to the inner aspect of the upper thigh.

Stage 5- Sexual maturity- normal adult- appears to the inner aspect of upper thigh .

b. Labia Majora – ―large lips‖- longitudinal fold , extends symphysis pubis to perineum

c. Labia Minora or ― Nymphae‖—soft & thin longitudinal fold located bet labia majora

2 Sensitive Structures
1. Clitoris- ―Pea-shaped‖- Anterior portion. Erectile tissue w/ lots sensitive nerve endings.
Sight of sexual arousal (Greek-key)

2. Fourchett- Posterior portion. Tapers posteriorly of the labia minora

Sensitive to manipulation, torn during delivery.
Common site for episiotomy
d. Vestibule
– an almond shaped area that contains the hymen, vaginal orifice &
bartholene‘s glands,urinary meatus & skene‘s glands.

1. Urinary Meatus – small opening of urethra, serves for urination

2. Skene‘s Glands/or Paraurethral gland –2 small mucus secreting substances for lubrication
3. Hymen – covers vaginal orifice, membranous tissue

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 4. Vaginal Orifice – external opening of vagina
5. Bartholene‘s Glands- Paravaginal gland or vulvo gland -2 small mucus secreting substance
– secrets alkaline subs. *Neutralizes the vagina
*Alkaline – neutralizes acidity of vagina
*Ph of vagina - acidic
*Doderleins Bacillus – responsible for the acidity of vagina
*Carumculae Mystiformes- healing of torn hymen

e. Perineum – muscular structure in between the lower vagina & anus

2. Internal

a. Vagina – female organ of copulation, passageway of menstruation & fetus.

3 – 4 inches or 8 – 10 cm long, dilated canal contains rugae
Rugae – permits stretching without tearing

b. Uterus- organ of menstruation--a hollow, thick walled muscular organ. It varies in size,
weight & shape
Size - 1 x 2 x 3 meters
Shape: Non-pregnant ―Pear shaped‖
Pregnant – ―Ovoid‖

Weight: Non-pregnant – 50 -60 kg

Pregnant – 1,000g Process:
4th stage of labor - 1000g Involution of uterus
2 weeks after delivery - 500g
3 weeks after delivery - 300 g
5-6 weeks after delivery50 – 60

3 Parts of the Uterus

1. Fundus - *Upper cylindrical layer
2. Corpus/body - Upper triangular layer space in between --Isthmus
3. Cervix - *Lower cylindrical layer
* Isthmus----- lower uterine segment during pregnancy

Muscular Compositions: 3 main muscle layers which make expansion possible in every direction.

1. Endometrium- inside uterus, lines the nonpregnant uterus. *Muscle layer for menstruation.
Sloughs during menstruation.
*Decidua- thick layer w/c lines the pregnant uterus.
Endometriosis-abnormal growth of endometrial lining outside uterus―Ectopic endometrium‖
Common site: Ovary.
S/sx: Dysmennorhea & low back pain.
Dx: Biopsy & Laparoscopy
Meds: 1. Danazol (Danocrene)---action: stop menstruation & inhibits ovulation
2. Luprolide (Lupron) –action: inhibit FSH/LH production

2. Myometrium – largest part of the uterus, muscle layer for delivery process
 Its smooth muscles are considered to be the living ligature of the body.
 Power of labor, responsible for contraction of the uterus
3. Perimetrium – Protects entire uterus

c. Ovaries – 2 female sex glands, ―almond shaped‖.

2 Function: 1. Ovulation
2. Production of estrogen & progesterone
*Cortex of Ovary---- releases the mature ovum
d. Fallopian tubes – 2-3 inches long that serves as a passageway of the sperm from the uterus to
the ampulla or the passageway of the mature ovum or fertilized ovum
from the ampulla to the uterus.

4 Significant Segments

1. Infundibulum – distal part of fallopian tube, ―Trumpet or Funnel shaped

2. Ampulla – outer 3rd or 2nd half of the fallopian tube
3. Isthmus – *site of sterilization & common site for bilateral tubal ligation
4. Interstitial – most dangerous site of ectopic pregnancy ( 10 m in diameter)
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 B. Male Reproductive System

1. External

Penis – the male organ of copulation & 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 clitoris in the female – 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.
- cooling mechanism of testes
- < 2 degrees C than body temp.
- Leydig cell – release testosterone
Testes---- for continuous spermatogenesis

2. Internal
The Process of Spermatogenesis – maturation of sperm

Testes -------------900 coiled (½ meter long at age 13 onwards)

(Seminiferous tubules)

Epididymis -------------6 meters coiled tubules, *Site for maturation of sperm

Vas Deferens ---------*Conduit for spermatozoa or pathway of sperm

Seminal vesicle-- secretes: Fructose – glucose has nutritional value.

Prostaglandin- causes reverse contraction of uterus
Ejaculatory duct---------*Conduit of semen

Cowpers gland ------------releases alkaline substance

(Bolbourethral glands)

Urethra

*Beginning of spermatogenesis--- 13 y/o onwards

*Gynecomastia ----enlargement of male breast

*Androphous-------male menopause

*Leydig Cell--------releases testosterone

*Ideal child-bearing age------20-30 y/o
*High Risk---------------------<18 & >35 y/o
*With Risk-------------------- bet. 18-20 & bet. 30-35

Hypothalamus Male & Female Homologues

Male Female
Sperm Ovum
GnRH Penile Glans Clitoral Glans
Penile shaft Clitorial shaft
Anterior Pituitary Gland Testes Ovaries
Prostate Skene‘s Glands
Cowper‘s Glands Bartholene‘s Glands
Scrotum Labia Majora
FSH LH

Fx: Hormone for Fx: Responsible for

Sperm Maturation Testosterone Production

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 Secondary Sex Characteristics
Female Male
1. in height in weight
2. in pelvis diameter Growth of testes
3. Breast enlargement Growth of face, axillary & pubic hair
4. Pubic hair growth Voice changes
5. Onset of menstruation Penile growth
6. Growth of axillary hair in height
7. Vaginal secretions Spermatogenesis

III. BASIC KNOWLEDGE ON GENETICS & OBSTETRICS

1. DNA – carries genetic code

2. Chromosomes – threadlike strands composed of hereditary material – DNA
3. Normal amount of ejaculated sperm ------3 – 5 cc or 1 tsp.
4. Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation
5. Sperm is viable within 48 – 72 hrs, 2-3 days
6. Reproductive cells divides by the process of Meiosis (haploid)
*Spermatogenesis – process of maturation of sperm
*Oogenesis – process of maturation of ovum > 1 ovum & 3 by-product
*Gematogenesis – formation of 2 haploid into diploid 23 + 23 = 46 or diploid

Male: X or Y Ovum: 23 chromosomes

Female : X or X Sperm: 23 chromosomes ( 22 autosomes –determines the traits)

(determines the sex of baby either X or Y) + 1

*Father : carries the sex chromosomes
7. Age of Reproductivity: 15 – 44 y/o

8. Menstruation:
Menstrual Cycle------------------- beginning of menstruation to beginning of next menstruation
Average Menstrual Cycle –------ 28 days
Average Menstrual Period-------- 3 – 5 days
Normal Blood loss---------------- 50 cc or ¼ cup, accompanied by ―Fibrinolysin‖—prevents clot formation

Related Terminologies:
Menarche--------– 1st mens
Dysmenorrhea – painful menstruation -----give Mefenamic: act as anti-prostaglandin
Metrorrhagia-----bleeding between menstruation
Menorhagia ------excessive during menstruation
Amenorrhea-------absence of menstruation
Menopause --------cessation of mens. *Average menopausal age : 51 years old
-dependent on the # of kids you have
Needs of Menopausal Women: Menopause

Estrogen

Prone to osteoporosis ---eat Tofu: with Isoflavones

Estrogen of plants that mimics the estrogen of woman

9. Functions of Estrogen & Progestin

* Estrogen ―Hormone of the Woman‖

Primary Fx: Development of secondary sexual characteristics in female.
Others:
1. Inhibit production of FSH ( maturation of ovum)
2. Responsible for hypertrophy of myometrium
3. Spinnbarkeit & Ferning ( billings method/ cervical)
4. Development ductile structure of breast
5. Increase osteoblastic activity of long bones
6. Increase in height in female
7. Causes early closure of epiphysis of long bones
8. Causes sodium retention
9. Increase sexual desire
10. vaginal lubrication
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 *Progestin ― Hormone of the Mother‖
Primary Fx: Prepares endometrium for implantation, make it thick & tortous (twisted)
Secondary Function: Inhibits uterine contractility (favors pregnancy)
Others:
1. Inhibit production of LH ------LH: hormone for ovulation
GIT Motility 2. Decreased GIT motility
3. Mammary gland development
Peristalsis 4. Increase permeability of kidney to lactose & dextrose causing (+) sugar (N)
5. Causes mood swings in moms
H2O reabsorption 6. Elevated BBT

Constipation

10. Menstrual Cycle

Parts of body responsible for Menstruation: 1. Hypothalamus

2. Anterior pituitary gland – master clock of body
3. Ovaries
4. Uterus

4 Phases of Menstrual Cycle: CHANGES IN HORMONE LEVEL

1. Proliferative: 6-14 days 3rd day – decreased estrogen : Initial phase

2. Secretory : 15-26 days---best time for implantation 13th day – Peak estrogen, : Decrease progestin
3. Ischemic : 27-28 day 14th day – Increase estrogen, : Increase progestin
4. Menses : 1-5 days 15th day – Decrease estrogen : Increase progestin

I. On the initial 3rd phase of menstruation , the estrogen level is ,this level stimulates the hypothalamus to
release GnRH or FSHRF

I. GnRH/FSHRF – stimulates the anterior pituitary gland to release FSH

Functions of FSH:

1. Stimulate ovaries to release estrogen

2. Facilitate growth primary follicle to become Graffian Follicle

secrets large amount of estrogen & contains mature ovum

II. Proliferative Phase – proliferation of tissue ―Estrogenic Phase 1st Phase

Follicular Phase ( 14 days) 4 Phases in Increase Estrogen of
Postmenstrual Phase Menstrual Cycle
Preovulatory Phase – phase increase estrogen

 The phase responsible for irregularities of menstruation

III. 13th day of menstruation, estrogen level is peak while the progesterone level is , these stimulates the
hypothalamus to release GnRF / LHRF

S & Sx:
 Mittelschsmerz – the slight abdominal pain on L or RQ of abdomen, marks ovulation day.
 Change in BBT, mood swing

IV. GnRF/LHRF stimulates the APG to release LH.

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 Functions of LH:

1. Stimulates ovaries to release progesterone

2. Hormone for ovulation
VI. 14th day estrogen level is while the progesterone level is causing rupture of graffian follicle known as ―Ovulation‖
V. 15th day, after ovulation day, graffian follicle starts to degenerate becoming yellowish known as Corpus Luteum

secrets large amount of progesterone, little estrogen: life span of 14 days

VI. Secretory phase 2nd Phase of MenstrualCycle

Luteal Phase 4 Phases in Increase Progesterone
Postovulatory Phase
Premenstrual Phase

IX. 24th day if no fertilization, corpus luteum degenerate becoming whitish---------Corpus Albicans

X. 28th day – if no sperm in ovum – endometrium begins to slough off to begin the next menstruation

Physiology: Hypothalamus

GnRH -------hormone that begins menstruation

APG -----to ovaries

FSH LH

11. Stages of Sexual Responses (EPOR)

Initial responses: Vasocongestion – congestion of blood vessels

Myotonia – increase muscle tension

1. Excitement Phase – erotic stimuli cause increase sexual tension, lasts minutes to hours.
Sx: for both---- moderate increase in HR, RR,BP, sex flush, nipple erection, increase muscle tension

2. Plateau Phase – increasing & sustained tension nearing orgasm. Lasts 30 seconds – 3 minutes.
Sx: for both--- increase voluntary & involuntary muscle, accelerated V/S

3. Orgasm – immeasurable peak of sexual experience & involuntary spasm throughout body. Involuntary release of sexual
tension with physiologic or psychologic release. May last 2 – 10 sec- most affected are is pelvic area.
Sx: involuntary spasm throughout body, peak v/s
Male: 2-3 contraction
Female: 5-12 contraction

4. Resolution – (v/s return to normal, genitals return to pre-excitement phase)

*Refractory Period – the only period present in males, w/n he cannot be restimulated for about 10-15 minutes

IV. WONDERS OF FERTILIZATION

A. Fertilization

1. Stages of Fetal Growth & Development

*Pre-embryonic Stage
a. Zygote ------fertilization up to 14th day.
------Lifespan of zygote – from fertilization to 2 months
b. Morula ----- mulberry-like ball with 16 – 50 cells/ 4 days free floating & multiplication

c. Blastocyst – enlarging cells that forms a cavity & later becomes the embryo.

*Trophoblast ---- covering of blastocys that later becomes placenta & trophoblast
*Cornix- where sperm is deposited after entering the vagina
*Sperm- small head, long tail, pearly white
*Phonones-vibration of head of sperm to determine location of ovum
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 *Sperm should penetrate corona radiata and zona pellocida.
*Corona Radiata – outer layer of ovum
*Zona Pellucida – inner layer of ovum
*Capacitation- ability of sperm to release proteolytic enzyme to penetrate corona radiata & zona pellocida.
d. Implantation/ Nidation - occurs after fertilization 7 – 10 days.

Normal implantation------ upper portion

-------lower portion -----placenta previa
Signs of implantation:
 Slight pain
 Slight vaginal bleeding

3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion
*If with fertilization – corpus luteum continues to function & become source of estrogen & progesterone
while placenta is not developed.

Physiology: Zygote -------sperm + ovum

Travels 3-4 days (mitotic cell division begins)

Uterus Names
Zygote: Fertilization to 14th day
Morula Embryo: 15th day to 2 months/8 wks.
Floats in the uterus 3-4 days Fetus : 2 months to birth

Blastocysts

*Embroyonic Stage

e. Dicidua – thickened endometrium ( Latin – falling off)

* Basalis: (base) part of endometrium located under fetus where placenta is developed,
this is located where implantation occurs
* Capsularies – encapsulate the fetus/ located on the backside
* Vera – remaining portion of endometrium.

f. Chorionic Villi- finger life projections that develops 10 – 11th day of pregnancy

*Chorionic Villi Sampling (CVS) ----- removal of tissue sample from the fetal portion of the developing placenta for
genetic screening.
>Done early in pregnancy around 9-12 wks.
>Common complications: Fetal limb defect. Ex. missing digits/toes.

g. Cytotrophoblast –outer layer or ―Langhans layer‖ – protects fetus against syphilis up to 24 wks/6 months
then degenerates at 16 wks.

h. Synsitiotrophoblast –inner layer or ―Synsitial layer‖ – responsible production of hormone

1. Amnion – innermost layer

a. Umbilical Cord or ―FUNIS‖

 Whitish grey
 15 – 55cm or 20 – 21‖
 Protected by Wharton‘s Jelly.
 3 vessels: A – unoxygenated blood
V – O2 blood
A – unoxygenated blood
 Short cord----- abruptio placenta or invertion of uterus.
 Long cord------cord coil or cord prolapse

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 b. Amniotic Fluid – or ―Bag of Water‖

 Clear, odor mousy/musty w/ crystallized forming pattern, slightly alkaline.

 Normal amount of amniotic fluid : full term----500 -1,000 cc
 > 1,000 is Polyhydramnios----- GIT malformation (TEF/TEA)
 <500 is Oligohydramnios------ kidney disease ,malformation
*Function of Amniotic Fluid:

1. Cushions fetus against sudden blows or trauma

2. Facilitates musculo-skeletal development
3. Maintains temperature
4. Prevent cord compression
5. Help in delivery process

Diagnostic Tests for Amniotic Fluid

a. Amniocentesis
N.I : 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- Maternal Serum Alpha Feto-Protein Test (MSAFP)

-Early Screening ----1st trimester
- Decrease MSAFP------Down Syndrome
- Increase MSAFP-------Spina Bifida or Open Tube Neural Defect
2. Determination of fetal maturity primarily by evaluating factors indicative
of lung maturity
- Late Screening------ 3rd trimester
a. Testing time ------- 36 weeks
b. Definitive Test for lung maturity--Phosphatiglycerol or PG+

Surfactant---- to prevent lung collapse

-Lecithin Sphingomyelin L/S
- Uses the L:S ratio of 2:1 ( shake or foam test) Shake test – amniotic + saline & shake
- If decrease L:S ratio ----indicative of RDS
*Common complication Amniocentesis : Infection
*Dangerous complications : Spontaneous Abortion
*Important factor to consider for amniocentesis: needle insertion site
* Primary Indication for early screening: Advanced Maternal Age
*Primary Indication for late screening: DM Mother

AMNIOTIC FLUID EVALUATION

1. Yellowish – Jaundice/ Hyperbilibirubinemia

2. Greenish – Meconium stained
3. Cloudy - infection

b. Amnioscopy – direct visualization or exam to an intact fetal membrane.

c. Fern Test- determine if bag of water has ruptured or not. Done for laboring mother

d. Nitrazine Paper Test –use to differentiate amniotic fluid & urine.

Paper turns yellow- urine.
Paper turns blue green/gray-(+) rupture of amniotic fluid.

2. Chorion – outermost membrane, where placenta is developed

a. Placenta or ―Secundines‖ combination of chorionic villi + deciduas basalis.

- Size: 500g or ½ kg
-8 inches long & 1 inch thick
-Cotylydon = 15-28 pcs.

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 Functions of Placenta:
1. Respiratory System- exchange of O2 & CO2 via simple diffusion
-use it as the breathing system not the lungs
- beginning of lung function after 1st cry of baby.

2. GIT –as a transport center like glucose transport thru facilitated diffusion (rapid)
If mom hypoglycemic then fetus hypoglycemic too
3. Excretory System- waste products carried by arteries. Liver of mom detoxifies waste.

4. Circulating system – Fetoplacental circulation achieved by selective osmosis

5. Endocrine System – produces hormones
 Human Chorionic Gonadrophin (HCG)
Primary Purpose: Maintains corpus luteum alive
Secondary Purpose: Basis of Pregnancy
 Human Placental Lactogen (HPL) or sommamommamotropin Hormone
 Responsible for mammary gland development
 Has a diabetogenic effect – serves as insulin antagonist
 Relaxin Hormone- for softening of maternal joints & bones
 Estrogen
 Progestin
*Mother needs increase insulin support as pregnancy progresses
6. It serves as a protective barrier against some microorganisms – HIV,HBV,CMV,Rubella

*Fetal Stage ― Fetal Growth & Development‖

*Entire pregnancy days : 266 – 280 days or 37 – 42 weeks *280/28 days = 10 lunar months
*280/30 days = 9.7 calendar month
First trimester: Period of Organogenesis/ Development of Organs
*Most Critical Period

1st month : Brain & Heart development

1. FHT begins – heart is the oldest part of the body
2. CNS develops – gives dizziness to mom d/t hypoglycemic effect
 GIT& URT – remains as single tube
Glucose -Food of brain ----gives as complex CHO ex. potato, tuna

 Differentiation of Primary Germ layers---by end of 2nd week

* Endoderm - Thyroid – for basal metabolism
- Parathyroid - for calcium
- Thymus – development of immunity
- Liver & lining of upper RT & GIT

* Mesoderm - Heart, musculoskeletal system, Kidneys, Reproductive organs

* Ectoderm -Brain, CNS, skin, 5 senses, mucus membrane of hair, nails, anus & mouth

2nd Month : All vital organs are formed

 Placenta developed
 Sex organ formed
 Meconium is formed
 Corpus luteum – source of estrogen & progesterone of infant – life span & functions till
end of 2nd month

3rd Month : Placenta is Complete

 Kidneys functional
 Buds of milk teeth appear
 Fetal heart tone heard by Doppler at 10 – 12 weeks
 Sex is distinguishable

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Second Trimester: Period of Continuous Growth & Development
*Focus ----length of fetus

4th Month :
 Lanugo begins to appear
 FHT audible by fetoscope (18 – 20 wks.)
 Buds of permanent teeth appear
 Meconium is present

5th Month :
 Quickening : 1st fetal movement used for EDC (Primi: 18- 20 wks.) (Multi: 16- 18 wks)
 Lanugo covers body
 Actively swallows amniotic fluid
 FHT audible by stet w/ or w/o instrument
 19-25 cm fetus
 Actively swallow amniotic fluid
6th Month :
 Eyelids open
 Skin red & wrinkled
 Vernix caseosa covers the skin
 Exhibits startle reflex
 Sucking

Third trimester: Period of Most Rapid Growth

*Focus : Weight of fetus

7th Month:
 Development of surfactant – lecithin
 Male : testes begin to descend into scrotal sac
 Female : clitoris is prominent & labia majora are small & do not cover labia minora

8th Month:
 Lanugo begin to disappear
 Sub Q fats deposits, steady weight gain occurs
 Nails extend to fingers
 Active Moro reflex is present
 Nails longer to fingers

9th Month:
 Lanugo & vernix caseosa begins to thin
 Amniotic fluid decreases
 Birth position is assumed
 Sole of foot has few creases

10th Month:
 Bone ossification of fetal skull
 Vernix caseosa is evident in body folds

*Moulding – no longer occurs for post-term babies

TO CONSIDER:

Terratogens- 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 : Ototoxicity & deafness
Tetracycline – staining of tooth enamel, inhibits growth of long bone
Vitamin K – Hemolysis, hyperbilirubenimia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia (absence of extremities) or pocomelia (Absence of distal parts of extremeties)
Steroids – cleft lip or palate or abortion
Lithium – anti-manic may cause congenital malformation

B. Alcohol – LBW (vasoconstriction –monther/ FAS or fetal alcohol syndrome ---characterized by microcephaly
C. Smoking – LBW
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 D. Caffeine – LBW
E. Cocaine – LBW w/c causes vasoconstriction leads to abruptio placenta

TORCH (Terratogenic) Infections – viruses

CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth
canal and adversely affect 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
chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus.

T – toxoplasmosis – handling of cat litter or raw vegetables or meat

O – others. Hep. A or Hep. 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. Don‘t get pregnant for 3
months. Vaccine is terratogenic
C – cytomegalo virus
H – herpes simplex virus
V. Physiological Adaptation of the Mother to Pregnancy

1. Systemic Changes

A. Cardiovascular System
 Normal increase blood volume of mother----- 1,500 cc (+500 for multiple pregnancy)
 Plasma volume increase only
 Increase cardio workload-------easy fatigability
 Slight hypertrophy of ventricles
 Epistaxis d/t hyperemia of nasal membrane
 Palpitation d/t stimulation of CNS

1. Physiologic Anemia ---- Normal (pseudo anemia of pregnant women)

Normal Values
Hct 32 – 42%
Hgb 10.5 – 14g/dL
Criteria
1st and 3rd trimester : HCT >33% & Hgb >11g/dL
Pathologic anemia if lower
2nd trimester – Hct >32% & Hgb >10.5 g/dl
Pathologic anemia if lower
3. Pathogenic Anemia
-Iron deficiency anemia is the most common hematological disorder.
It affects 20% of pregnant women.

Assessment reveals:
 Pallor, constipation
 Slowed capillary refill * Normal Capillary Refill: 2-3 seconds)
 Concave fingernails (late sign of progressive anemia) d/t chronic physio hypoxia
Nursing Care:
 Nutritional instruction
Sources of Iron: kangkong---most common source
Liver ---richest source d/t ferridin content
Green leafy vegetable-alugbati,saluyot, malunggay, horseradish, ampalaya
 Parenteral Iron ( Imferon) – for severe anemia
give IM---Z tract- if improperly administered------Hematoma
 Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day)
-Anti-sebum: best given before meals or 2 hrs after, black stool, constipation
 Monitor for hemorrhage

Alert:
 Iron from red meats is better absorbed iron from other sources.
 Iron is better absorbed taken w/ Vit. C such as orange juice
 Higher iron intake is recommended since circulating blood volume is increased & heme is required
from production of RBCs

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 4. Edema – lower extremities in pregnant women normal--- d/t venous return---constricted d/t large belly
N.I. -----Elevate legs above hip level
*Responsible for venous return----muscle contraction

5. Varicosities – pressure of uterus

N.I ----use support stockings, avoid wearing knee high socks
---use elastic bandage – lower to upper, elevate legs
*Vulbar varicosities- painful, pressure on gravid uterus
Relieve by positioning – side lying w/ pillow under hips or modified knee chest position

6. Thrombophlebitis or “Deep Vein Thrombosis” – presence of thrombus at inflamed blood vessel

 Pregnant body: Altered hyperfibrinogenemia

 Increase fibrinogen to prevent hemorrhage & increase clotting factor
 Thrombus formation candidate
 Outstanding sign : (+) Homan's sign (pain on calf during dorsiflexion)
 ―Milk leg‖ or phagmasia alba dolens: the shiny white legs d/t stretching of skin caused by
inflammation
Mgt For Thrombosis:
1.) CBR
2.) Never massage
3.) Check dorsalis pedis pulse (distal)
4.) Assess for (+) Homan sign only once to prevent dislodge of thrombus
5.) Avoid aspirin! Might aggravate bleeding.
6.) Give anticoagulant to prevent additional clotting
Ex. Heparin (it does not cross placental membrane)

Antidote: Protamine Sulfate (no aspirin)

Monitor APTT (best) then PTT
7.) Then thrombolytics----dissolve the clotting

B. Respiratory System

1. Common problem: SOB d/t enlarged uterus & increase O2 demand

N.I. ----position in a side lying position to allow expansion of lungs

C. Gastrointestinal

1. Morning Sickness– 1st trimester change is normal

- Nausea & vomiting d/t increase HCG
N.I.> Eat dry crackers or CHO diet 30 minutes before arising from bed
>PM: small frequent meals
-Metabolic alkalosis if F&E imbalance – primary med mgt – replace fluids.
>Waist up-----acid lost ----alkalosis
>Waist down—bicarbonate lost----acidosis
>Monitor I&O
-Vomiting in pregnancy ----Emesis Gravidarum----if too much Hyperemesisgravidarum

2. Constipation –2nd trimester changes

-Cause by progesterone, decrease motility causes increase fluid absorption
N.I.---Increase fluid intake & increase fiber diet
>Fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple w/ skin, suha.
Except guava – has pectin that‘s constipating – veg – petchy, malungay.
>Exercise
> No Mineral oil –facilitates excretion of fat soluble vitamins
3. Flatulence
-D/t increase progesterone
N.I.---Avoid gas forming food – cabbage

4. Heartburn or Pyrosis
-Reflux of stomach content to esophagus
N.I.----- small frequent feeding, avoid 3 full meals
Diet: avoid fatty & spicy food, sips of milk
Proper body mechanics----avoid downward positioning
*Ptyalism-- --increase salivation---– mgt mouthwash

12
 5. Hemorrhoids
-Cause by pressure of gravid uterus
N.I.----Hot sitz bath for comfort, avoid hot & spicy foods

C. Urinary System
-Frequency of urination: 1st & 3rd trimester only
-Lateral expansion of lungs or side lying pos – mgt for nocturia

1st trimester – normal frequency of urination

2nd trimester- normal--- (+) 1 sugar
Tests:
*Heat Acetic Test –determine albumin & sugar in urine
*Benedict‘s Test –determine sugar in urine

D. Musculoskeletal

1. Lordosis or “Pride of pregnancy‖

2. Waddling Gait – awkward walking dt relaxin – causes softening of joints & bones
N.I.----Prone to accidental falls – wear low heeled shoes

3. Leg Cramps
-Causes: prolonged standing, over fatigue,chills, oversex
- #1 cause during pregnancy: Ca & phosphorous imbalance
- During labor: Compression of lumbo sacral nerve plexus by the gravid uterus
-Immediate relief---dorsiflexed feet
Mgt: Increase Ca & Inc phosphorus)----milk ---1pint/day or 3-4 servings/day.
Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli,
seafood-tahong (mussels), lobster, crab.
Vit D for increased Ca absorption

2. Local Changes

A. Vagina:
U – Hegar's Sign -------- -change in consistency of isthmus (lower uterine segment)
C – Goodel's Sign -------change in consistency of cervix
V – Chadwick‘s Sign ---bluish violet discoloration of vagina &cervix

LEUKORRHEA – whitish gray,moderate amount, mousy odor discharge---d/t Estrogen

OPERCULUM – mucus plug to seal out bacteria.--------d/t progestin

Problems Related to the Change of Vaginal Environment:

a. Vaginitis
-CA: Trichomonas vaginalis---a Flagellated protozoan – likes alkaline env‘t.
-D/t alkaline environment of vagina of pregnant mom
-Pregnant: acidic to alkaline change to protect bacterial growth (vaginitis)
S & Sx:
-Greenish, cream-colored frothy discharge
-Irritatingly itchy with foul smelling odor with vaginal edema
Mgt:
1. Anti-protozoan ----FLAGYL (Metronidazole).
-Teratogenic drug especially at 1st trimester (do not give too early)
-Treat also the partner to prevent reinfection
-No alcohol-----antaabuse effect
2. VAGINAL DOUCHE – I quart H2O : 1 tbsp white vinegar

b. Moniliasis or Candidiasis
-CA: Candida Albecans ( a fungal infection)
S & Sx:
-White cheese-like patches that adheres walls of vagina.
- Baby with oral thrust if vaginal delivery
Mgt:
1. Antifungal------Nystatin, Mycostatin, Gentian violet, Cotrimaxole
13
 c. Gonorrhea
-Thick purulent discharge

d. Vaginal Warts
- Condylomata Acuminata
-CA: Papilloma virus
Mgt: Cauterization

B. Abdominal Changes

a. Striae Gravidarium (stretch marks)—d/t enlarging uterus-destruction of sub Q tissues

N.I.---Avoid scratching, use coconut oil, umbilicus is protruding

C. Skin Changes

a. Melasma/Chloasma --white/ light brown pigmentation on nose chin, cheeks

d/t increased melanocytes.
b. Linea Nigra ----Brown to pinkish line from symphisis pubis to umbilicus
D. Breast Changes
-All changes r/t increase hormones
-Color & size of areola & nipple
-Pre-colostrum is present by 6 wks. & Colostrums at 3rd trimester
-BSE should be done 7 days after menstruation in a supine w/ pillow at back position
-Check at Upper outer quadrant --------most common site of breast cancer
Dx:
1. Biopsy or Mammography – 35 to 49 yrs once a year

E. Ovaries – rested during pregnancy

3. Signs & Symptoms of Pregnancy

A. Presumptive: S/S felt & observed by the mother but does not confirm (+) dx 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.

Presumptive Probable Positive

B-reast changes G-oodel's Sign ----consistency of cervix Ultrasound evidence
U-rinary frequency C-hadwick‘s Sign----color of vagina > Transvaginal
1st F-atigue H-egar's Sign --- consistency of isthmus (empty bladder)
Trimester A-menorrhea E-levated BBT----d/t increased progestin >Transabdominal
M-orning sickness P- ositive HCG (also sign of H-mole) (sonogram)
E-nlarged uterus (full bladder)

C-hloasma B-allottement : Fetal heart tone

2nd L-inea negra E-nlarged abdomen Fetal movement
Trimester I-ncreased skin pigmentation B-raxton Hicks contractions Fetal outline
S-triae gravidarium Fetal parts palpable
Q-uickening

*Ballotment - bouncing of fetus when lower uterine is tapped sharply (also present in uterine myoma)
*Braxton Hicks– painless irregular contractions

*Ultrasound Placental Grading – rating/grade

0 – Immature
1 – Slightly mature
2 – Moderately mature
3 – Placental maturity (fully mature)
* Calcification: Calcium deposited in the placenta to determine its maturity

14
VI. Psychological Adaptation to Pregnancy

By: Reva Rubin------- Theory Of Maternal Role Attainment (MRA)

The emotional response of the mother to pregnancy

1st Trimester:
 No tanginal S & Sx
 Feeling of Surprise, Ambivalence & Denial – sign of maladaptation to pregnancy
 Developmental Task: Accept the biological facts of pregnancy
 HT Focus: Bodily changes of pregnancy & nutrition

2nd Trimester:
 Tangible S&Sx
 Mother identifies fetus as a separate entity d/t presence of quickening
 Fantasy
 Developmental Task: Accept growing fetus as baby to be nurtured
 HT: Growth & Development of fetus.

3rd Trimester:
 Mother has personal identification w/ the appearance of the baby
 Development Task: Prepare for birth & Parenting of child
 HT: Responsible parenthood ---best time to prepare ‗baby‘s Layette‖ ,Lamaze class, shopping.
 Allay fear of mother-----let mom listen to FHT
VII. Pre-Natal Visit:

Basic Considerations:

1. Frequency of Visit: 1st 7 months - 1x a month

8th – 9th months - 2 x a month
10th month - once a week
Post-term - 2 x a week
2. Personal Data
-Name
-Age---to determine if high risk pregnancy (High risk < 18 & >35 yrs old)
-HBMR. Home Base Mother‘s Record.
-Sex

*Pseudocyesis----false pregnancy on men & women

*Couvade Syndrome –psychosomatic reaction where the father experiences
what the mother goes through – lihi
-Address, civil status, religion, culture & beliefs with respect, non judgmental
-Occupation – financial condition/ occupational hazards, education background: level knowledge

3. Diagnosis of Pregnancy
1.) Urine Exam---to test for HCG –present on 40 – 100th day of pregnancy
*Peak of HCG : 60th – 70th day
*Do Urine test: 6 weeks after LMP- best to get urine exam.

2.) Elisa Test – test for early pregnancy to detect beta subunit of HCG as early as 7 – 10days

3.) Home Pregnancy Kit – do it yourself, 1 bar (-), 2 bar (+)

4. Baseline Data:
a. Focus: V/S especially BP
b. Roll-Over Test – to determine pre-eclampsia
-Side-lying position 10-15 minutes then supine & get BP, if >30/15mmHg (+)
c. Monitor patterns of weight gain (Increase wt – 1st sign preeclampsia)

Weight Monitoring
1st Trimester: Normal Weight Gain 1.5 – 3 lbs (.5 – 1lb/month)
2nd Trimester: Normal Weight Gain 10 – 12 lbs (4 lbs/month) or (1 lb/wk)
3rd Trimester: Normal Weight Gain 10 – 12 lbs (same w/ 2nd)
*Minimum Wt Gain: 20 – 25 lbs
*Optimal Wt Gain: 25 – 35 lbs

15
5. Obstetrical Data:
a. Nullipara – no pregnancy
b. Gravida - # of pregnancy
c. Para - # of viable pregnancy

*Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age,
still counted if the stillbirth is more than 20 wks old.
*Age of Viability: 20 weeks
*Abortion : <20 weeks
*Term : 37 – 42 wks.
*Preterm : >20 & <37 wks
*GTPAL: 5 digits----Gravida, Para, Term, Abortion, Living
Sample Cases:
1 – abortion GTPAL *Twins: considered as 1 pregnancy
1 – 2nd mo 2 0 01 0
G–2
P–0

1 – 40th AOG GT P A L
1 – 36th AOG 612 2 4
2 – miscarriage
1 – twins 35 AOG
1 – 4th month G6 P3

Important Estimates:

1. Nagele’s Rule : Use to determine expected date of delivery (EDD or EDC)

 Get LMP

Formula:
If LMP: January-March + 9 months April – December: - 3 months
+ 7 days + 7 days
+ 1 year

Ex. LMP Jan 25, 04 then +9 +7 = 10 / 32 / 04 = - 1, add 1 month to month = 11/31/04 EDD

2. McDonald’s Rule : Use to determine age of gestation IN WEEKS, if LMP not available

Formula: Fundic HT in cm x 7/8 = AOG in WK

Ex. From sypmhisis pubis to fundus 24 X 7 =21 wks

8
3. Bartholomew’s Rule : Use to determine age of gestation by proper location of fundus at abdominal cavity.

3 Months: Just above symphysis pubis

5 Months: Level of umbilicus
9 Months: Below xiphoid process
10 Months: Level of 8 months d/t lightening (32 wks.)

4. Haase’s Rule: Use to determine length of the fetus in cm.

Formula: 1st ½ of pregnancy= month 2
2nd ½ of pregnancy= month x 5
3mos x 3 = 9cm 6 x 5 = 30 cm
4 mos x 4 = 16 cm 1st ½ of pregnancy 7 x 5 = 35 cm 2ND ½ of pregnancy
5 x 5 = 25 cm 8 x 5 = 40 cm
9 x 5 = 45 cm
10 x 5 = 50 cm

16
6. Tetanus Immunizations
- Best way to prevent tetanus neonatum
- Given 5 times
- Mother w/ complete 3 doses DPT in childhood considered as TT1 & 2. Begin TT3

TT1 – any time during pregnancy - None

TT2 – 4 wks after TT1 or 1 month - 3 yrs protection
TT3 – 6 months after TT2 - 5 yrs protection
TT4 – 1 yr after TT3 - 10 yrs protection
TT5 – yr after TT4 - lifetime protection

7. Physical Examination:

A. Cephalocaudal: Examine teeth: if staining occurs-----sign of infection

Danger Signs of Pregnancy ―CABS‖

C – chills & Fever------- - infection

Cerebral Disorders----presence of headache ------sx of pre-eclampsia

A – abdominal pain-----presence of epigastric pain: aura of impending convulsions

B – boardlike abdomen -----check for abruptio placenta
BP elevated--------HPN
Blurred vision------preeclampsia
Bleeding ----------1st trimester: Abortion, Ectopic &
2nd trimester:H-Mole & Incompetent Cervix
3rd trimester: Placental Anomalies
S – sudden gush of fluid---- PROM -----prone to infection
Swelling-------edema to upper extremeties ----preeclampsia
Scotoma-----spots on eyes
B. Pelvic Examination or Internal Examination (IE)
 Done in 1st Trimester to check for presence of (+) signs
N.I.--- position in lithotomy, lift 2 legs at the same time
Empty bladder
Universal precaution

1. Pap Smear ( Papinicolaur

-a cytological exam to determine presence of cancer cells/ Cervical Ca
- Cancer cells ----composed of squamous columnar tissue
-External OS of cervix – site for getting the specimen
- Common site for cervical cancer-----External OS of Cervix

Result:
Class I - Normal
Class IIA – Acytology but no evidence of malignancy
B – Suggestive of inflammation
Class III – Cytology suggestive of malignancy
Class IV – Cytology strongly suggestive of malignancy
Class V – Cytology conclusive of malignancy

Stages of Cervical Cancer (1-4)

Stage 0 – Carcinoma in situ
1 – Cancer confined to cervix
2 - Cancer from cervix extends to vagina (upper 2/3 of vagina)
3 – Pelvis metastasis (pelvic wall)
4 – Affection to bladder & rectum

2. Leopold’s Maneuver
Purpose: Done to determine the attitude, fetal presentation, lie, presenting part,
degree of descent, an estimate of the size & # of fetuses, position,
fetal back( best site for FHT) & FHT
N.I.
- Use palm! Warm palm by rubbing briskly w/ each other
- Empty bladder
- Position mother: Dorsal Recumbent : supine w/ knee flex to
17
 relax abdominal muscles)
Procedure:
1st maneuver: Place patient in supine position with knees slightly flexed; put towel under
head & right hip; w/ both hands palpate upper abdomen & fundus.
Assess size, shape, movement & firmness of the part
to determine presentation:

Determine Presenting Parts: immovable, round, ballotable

2nd Maneuver: W/ both hands moving down, identify the back of the fetus (to hear FHT)
where the ball of the stethoscope is placed to determine FHT.
*Take Pulse before 2nd maneuver to differentiate between
Fundic soufflé (FHR) & Uterine soufflé (MHR)

3rd Maneuver: Using the right hand, grasp the symphis pubis part using thumb & 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: Examiner changes the position by facing the patient‘s feet. With 2 hands,
assess the descent of the presenting part by locating the cephalic
prominence or brow.
To determine attitude – relationship of fetus to 1 another.

When the brow is on the same side as the back, the head is extended.
When the brow is on same side as the small parts, head will be
flexed & vertex presenting.

*Attitude – relationship of fetus to its part – or degree of flexion

*Full flexion – when the chin touches the chest
8. Assessment For Fetal Well-Being

A. Ultrasound

B. Daily Fetal Movement Counting (DFMC) : Begin > 27 wks of pregnancy

-Done after a meal or breakfast when mother is fulll
Considerations:
-Fetal Sleep-Wake Pattern
- Maternal Food intake
-Drug use, nicotine use
-Environment stimuli
a. Cardiff count to 10 method – one method currently available
(1) Begin at the same time each day (usually in the morning, after breakfast) & count
each fetal movement, noting how long it takes to count 10 fetal movements (FMs)
(2) Expected Findings : Normal: 10-12 movements/hour
(3) Warning Signs:
a.) More then 1 hour to reach 10 movements
b.) Less then 10 movements in 12 hours(non-reactive- fetal distress)
c.) Longer time to reach 10 FMs 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: nonstress test (NST), biographical profile (BPP)

b. Nonstress Test: To determine the response of the fetal heart rate to activity
Indication – pregnancies at risk for placental insufficiency
Position: Semi-fowler‘s
a.) PIH, DM
b.) Warning signs noted during DFMC
c.) Maternal history of smoking, inadequate nutrition
d.) Postmaturity

18
 Procedure:
Done w/n 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 & 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
 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----indicates Fetal Distress Reactive----signify fetal well-being
Nonstress Responsive is
Not Good Real Good

Interpretation of Results
1. Reactive Result
a. Baseline FHR between 120 & 160 beats per minute
b. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least
15 seconds in a 10 to 20 minute period as a result of FM
c. Good variability – normal irregularity of cardiac rhythm representing a balanced
interaction between the parasympathetic (decreases FHR) & sympathetic (increase
FHR) nervous system; noted as an uneven line on the rhythm strip.
d. Result indicates a healthy fetus with an intact nervous system

2. NonReactive Result
a. Stated criteria for a reactive result are not met
b. Could be indicative of a compromised fetus.
Requires further evaluation with another NST, biophysical profile, (BPP)
or contraction stress test (CST)
9. Health Teachings

a. Nutrition – Do nutritional assessment – daily food intake

High Risk Mothers For Nutrition:

1. Pregnant Teenagers : poor compliance to heath regimen.
2. <18 y/o & >35 y/o
3. Extremes in weight: underweight----malnourished, Overweight-----candidate for HPN, DM
4. Low socio – economic status
5. Vegetarian mothers---decrease CHON

Needs Vit. B12 – cyanocobalamin

Needed for formation of folic acid

Needed for cell & DNA & RBC formation

*Decrease folic acid----leads to Spina Bifida/Open Neural Tube Defect
Assessment: 1. Ask the daily food intake
2. Needed calories of the mother
1st Trimester----no change
2nd & 3rd Trimester---additional 300kc/day (total of 2,500)
Lactating mother----- + 500 (total of 2,700)
Non-pregnant---------2,200 only
3. How many Kcal ? 1 CHO= 4 kilocalories
CHON x 4
FATS x 9
Total recommended Calories
4. Sodium = 3g/day ( eat in moderation)

19
 Recommended Nutrient Requirement That Increases During Pregnancy

Nutrients Requirements Food Source

Calories:
Essential to supply energy for
- Increased metabolic rate
- Utilization of nutrients
- Protein sparing so it can be used for
- Growth of fetus
- Development of structures required
for pregnancy including placenta,
amniotic fluid & tissue growth.
Protein
Essential for:
- Fetal tissue growth
- Maternal tissue growth including
uterus & breasts
- Development of essential pregnancy
structures
- Formation of RBC & plasma
proteins
* Inadequate protein intake has been
associated with onset of PIH
Calcium-Phosphorous
Essential for
- Growth & dev‘t of fetal
skeleton & tooth buds
- Maintenance of mineralization
of maternal bones and teeth
- Demonstrating an association
between adequate calcium
intake & the prevention of PIH
300 calories/day above the
pre-pregnancy daily requirement to maintain
ideal body weight & meet energy
requirement to activity level
- Begin increase in second trimester
- Use weight – gain pattern as an
indication of adequacy of calorie intake.
- Failure to meet caloric req. lead to ketosis
as fat & protein are used for energy;
ketosis associated with fetal damage.
60 mg/day or an increase of 10% above
daily requirements for age group
Adolescents have a higher protein
requirement than mature women since
adolescents must supply protein for their own
growth as well as protein to meet the
pregnancy requirement
Ca increases of
- 1200 mg/day representing an increase
of 50% above pre-pregnancy/ day
requirement.
- 1600 mg/day is recommended for the
adolescent. 10 mcg/day of Vit. D is
require, it enhances absorption of both
calcium & phosphorous
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 grains
*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 should reflect:
- Dairy products : milk,
yogurt, ice cream, cheese,
egg yolk
- Whole grains, tofu,Green
leafy vegetables
- Salmon & sardines w/ bones
- Ca fortified foods such as
orange juice
- Vitamin D : fortified milk,
margarine, egg yolk, butter,
liver, seafood

Iron 30 mg/day representing a doubling of the Iron increases should reflect

Essential for
- Expansion of blood volume & RBC
formation
- Establishment of fetal iron stores for
first few months of life
IRON INTAKE DOUBLES
DURING PREGNANCY
*Not given in the 1st half of
pregnancy-----aggravate discomfort
in the 1st half (nausea & vomiting)
-----GIT irritation---iron cause
constipation-----blakish discoloration
of stool
*Last 4 wks. ----greatest need—fetus
acquires iron reserves
Zinc
Essential for
* The formation of enzymes
* Maybe important in the prevention of
congenital malformation of the fetus.
Folic Acid, Folacin, Folate
Essential for
pregnant daily requirement - Liver, red meat, fish,
- Begin supplementation at 30- mg/day in poultry, eggs
2nd trimester, since diet alone is unable - Enriched, whole grain
to meet pregnancy requirement cereals & breads
- 60 – 120 mg/day along with copper & - Dark green leafy
zinc supplementation for women who vegetables, legumes
have low hemoglobin values prior to - Nuts, dried fruits
pregnancy or who have IDA - Vit. C sources: citrus fruits
- 70 mg/day of Vit. C which enhances & juices, strawberries,
iron absorption cantaloupe, broccoli or
- Inadequate iron intake results in cabbage, potatoes
maternal effects – anemia depletion of - Iron from food sources is
iron stores, decreased energy & appetite, more readily absorbed when
cardiac stress esp. labor & birth served with foods high in
- Fetal effects decreased availability of Vit. C
oxygen, affecting fetal growth
* Iron deficiency anemia is the most
common nutritional disorder of pregnancy.
Zinc increases should reflect
15mcg/day representing an increase of 3 - liver, meats
mg/day over pre-pregnant daily requirements. - shell fish
- eggs, milk, cheese
- whole grains, legumes,
nuts
Increases should reflect
400 mcg/day representing an increase of - liver, kidney, lean beef,

20
 - Formation of RBC & more then 2 times the daily prepregnant veal
prevention of anemia requirement. 300mcg/day supplement for - dark green leafy
- DNA synthesis & cell women with low folate levels or dietary vegetables, broccoli,
formation; may play a role in deficiency legumes.
the prevention of neutral tube *4 servings of grains/day - Whole grains, peanuts
defects (spina bifida), abortion,
abruption placenta
Additional Requirements Increased requirements of
Minerals pregnancy can easily be met with
- Iodine 175 mcg/day a balanced diet that meets the
- Magnesium 320 mg/day requirement for calories &
- Selenium 65 mcg/day includes food sources high in the
other nutrients needed during
pregnancy.
Vitamins Vit. stored in body
E 10 mg/day -Fat soluble Vits.---ADEK
Thiamine 1.5 mg/day -Not taken daily, can lead to
Riborlavin 1.6 mg/day toxicity. Hard to excrete.
Pyridoxine ( B6) 2.2 mg/day
B12 2.2 mg day
Niacin 17 mg/day

a. Sexual Activity-----------Principles in Sexual Activity

a. Should be done in moderation
b. Should be done in private place
c. Mother placed in comfortable position: side-lying or mom on top
d. Avoided 6 weeks prior to EDD
e. Avoid blowing of air during cunnilingus to prevent air embolism

Changes in Sexual Desire During pregnancy:

a.) 1st Trimester – decrease desire – d/t bodily changes
b.) 2nd trimester – increased desire d/t increase estrogen that enhances lubrication
c.) 3rd trimester – decreased desire
Contraindication In Sex:
1. Vaginal Spotting --1st trimester – threatened abortion, 2nd trimester– placenta previa
2. Incompetent cervix
3. Pre-term labor, Premature rupture of membrane
b. Exercise: During pregnancy to strengthen muscles that will be used during delivery process

Principles Of Exercise
1. Done in moderation
2. Must be individualized

a. Walking : Best form of exercise

b. Squatting : Strengthen muscles of perineum & increase circulation to perineum
-Squat – feet flat on floor
-Watch out for postural hypotension----raise buttocks before head

c. Tailor Sitting –same with squatting--- 1 leg in front of other leg ( Indian seat)

d. Kegel Exercise – strengthen pulococcygeal muscles (done 15 minutes/3x/day)

- As if hold urine, release 10x or muscle contraction

e. Shoulder Circling Exercise- strengthen chest muscles

f. Pelvic rocking/pelvic tilt- exercise – relieves low back pain & maintain good posture
* Arch back – standing or kneeling. Four extremities on floor
g. Abdominal Exercise – strengthens muscles of abdomen– done as if blowing candle

c. Childbirth Preparation:
Overall goal: To prepare parents physically & psychologically while promoting wellness
behavior that can be used by parents & family thus, helping them achieved a satisfying &
enjoying childbirth experience.

a. Psychophysical *Env‘t of Womb: warm,darkened,fluid-filled,quiet

21
 1. Bradley Method : By Dr. Robert Bradley
-Advocated active participation of husband as a coach at delivery process.
Based on imitation of nature.
Features:
1.) Darkened room
2.) Quiet environment
3.) Relaxation technique
4.) Closed eye & appearance of sleep

2. Grantly Dick Reed Method

-Based on fear leads to tension while tension leads to pain
-To decrease pain is to relieve fear
-Abdominal health exercise & relaxation technique

b. Psychosexual

1. Kitzinger Method : By Dr. Shela Kitzinger

-―Pregnancy, labor, birth & care of newborn is an important turning point in
the woman‘s life cycle‖
- Flow with contraction than struggle with contraction

c. Psychoprophylaxis: Prevention of pain

1. Lamaze: By Dr. Ferdinand Lamaze

-Prevention of pain thru the mind requiring discipline, conditioning &
concentration w/ the help of the husband to serve as a coach
Features:
1. Conscious Relaxation-relaxing the body part by part
2. Cleansing Breathe - inhale thru nose, exhale thru mouth
3. Effleurage – gentle circular massage over abdomen to relieve pain
4. imaging – sensate focus, imagining favorite person
d. Different Methods of Delivery:
1.) Birthing chair – bed convertible to chair – semi-fowler‘s position
2.) Birthing bed – Dorsal recumbent pos
3.) Squatting Position – relieves low back pain during labor
4.) Leboyer‘s Method – warm, quiet, dark, comfy room. After delivery, baby gets warm bath.
5.) Birth under water – bathtub – labor & delivery – warm water, soft music.
VIII. Intrapartal Notes – inside ER

A. Admitting the laboring Mother:

Personal Data: name, age, address, etc
Baseline Data: v/s especially BP, weight
Obstetrical Data: gravida # preg, para- viable preg, – 22 – 24 wks, add
Physical Exams,Pelvic Exams---empty bladder

B. Basic knowledge in Intrapartum.

1. Theories of the Onset of Labor

a. Uterine Stretch Theory: Any hallow organ stretched, will always contract & expel its content)- contraction action

b. Oxytocin Theory: PPG releases oxytocin---stimulates contraction. Hypothalamus produces oxytocin

c. Prostaglandin Theory-AA: stimulation of arachidonic acid – prostaglandin- contraction

*Prostaglandin in female stimulated by Arachidonic Acid (Fetal-Adrenal Response Theory)
d. Progesterone Deprivation Theory – before labor------decrease progesterone will stimulate contractions & labor

e. Theory of Aging Placenta – life span of placenta 42 wks. At 36 wks degenerates

(leading to contraction – onset labor).

22
2. The 4 P’s of labor

1. Passenger (baby)

a. Fetal head – is the largest presenting part:

Common presenting part – ¼ of its length.

Bones: 6 bones S – sphenoid F – frontal - sinciput

E – ethmoid O – occuputal - occiput
T – temporal P – parietal 2x
Measurement Fetal Head:
1. Transverse Diameter
Biparietal : 9.25 cm (largest TD)
Bitemporal: 8 cm
Bimastoid : 7cm (smallest TD)

2. AnteroPosterior Diameter
Suboccipitobregmatic: 9.5 cm (complete flexion, smallest AP)
Occipitofrontal: 12 cm partial flexion
Occipitomental: 13.5 cm hyper extension
Submentobragmatic: Face presentation

Sutures – intermembranous spaces that allow molding.

- Sagittal Suture – connects 2 parietal bones ( sagitna)
- Coronal Suture – connect parietal & frontal bone (crown)
- Lambdoidal Suture – connects occipital & parietal bone

Moldings: Overlapping of the sutures of the skull to permit passage of the head to
the pelvis

Fontanels: 6 Fontanels, 2 palpable

1.) Anterior Fontanel: (Bregma) Diamond shape
- 3 x 4 cm if > 5 cm ----hydrocephalus
- closes 12 to 18 months after birth
2.) Posterior Fontanel: (Lambda) Triangular shape
- 1 x 1 cm.
- Closes 2 to 3 months, earlier
2. Passageway (Vagina & Pelvis)

Problems in Passageway :
1. Mother < 4‘9‖ tall
2. < 18 years old
3. Underwent pelvic dislocation, or accident (cephalopelvic disproportion)
a. Pelvis
4 Main Pelvic Types

1. Gynecoid: Round, wide, deeper most suitable for pregnancy (Normal female pelvis)

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

supine A

Transverse

P
*Gynecoid & Anthropoid- can deliver vaginally

b. Bones of Pelvis-----4 bones

2 Hip Bones & 2 Innominate bones

23
 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 where we sit :landmark to get external measurement of pelvis

Pubes: Anterior portion

*Symphisis pubis- junction between 2 pubis
1 sacrum: Posterior portion
*Sacral prominence – landmark to get internal measurement of pelvis
1 coccyx : composed of 5 small bones that compresses during vaginal delivery

Important Measurements By Internal Exam:

1. Diagonal Conjugate – measure between sacral promontory & inferior margin of the
symphysis pubis.
Measurement: 11.5 cm - 12.5 cm
Basis in getting true conjugate.
(Formula : DC - 11.5 cm = True conjugate)

2. True Conjugate/Conjugate Vera – measure between the anterior surface of the sacral
promontory & superior margin of the symphysis pubis.
Measurement: 11.0 cm

3. Obstetrical Conjugate: smallest AP diameter of pelvis at 10 cm or more. Where the head will pass

Tuberoischi Diameter – transverse diameter of the pelvic outlet.

Ischial tuberosity – approximated with use of fist during lithotomy: 8 cm & above.
*Trial Labor—if passageway & fetus head exactly the same size

3. Power – the forces acting to expel the fetus & placenta *Myometrium – powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity

4. Psyche/Person – psychological stress when the mother is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
3. Pre-Eminent Signs of Labor

S&Sx:
- Shooting pain radiating to the legs
- Urinary frequency
1. Lightening: Settling of presenting part into pelvic brim. (Primi: 2 weeks prior to EDD)
(Multi- hours before labor)
* Engagement- setting of presenting part into pelvic inlet

2. Braxton Hicks Contractions – painless irregular contractions

3. Increase Activity of the Mother: ―Nesting instinct‖ d/t sudden rush of epinephrine
N.I. ---Conserve energy, will be used for delivery.
Fatigue may affect the type of anesthesia used
4. Ripening of the Cervix – comparable to butter soft
5. Decreased body wt. : 1.5 – 3 lbs
6. Bloody Show – pinkish vaginal discharge (Blood & leucorrhea & Operculom)
7. Rupture of Membranes – Check FHT 1st. If ruptured several hours----check temperature & FHT

Premature Rupture of Membrane ( PROM)

- Do IE to rule-out check for cord prolapse
Contraction drop in intensity even though very painful
Contraction drop in frequently
Uterus tense and/or contracting between contractions
24
 Abdominal palpations

Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP – most common malposition
Bear down with contractions
Adequate hydration – prepare for CS
Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is noted

Cord Prolapse – a complication when the umbilical cord falls/ is washed thru the cervix into the vagina.
*Cord Compression---if 5 minutes leads to irreversible brain damage---cerebral palsy
*An emergency-----position to a knee-chest or trendelenberg position

Danger Sx:
PROM
Presenting part has not yet engaged
Fetal distress----count pulsations of cord
Protruding cord from vagina

Nursing Care:
1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain
slippery & prevent cord compression
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS
5. Emotional support

Difference Between True Labor & False Labor

False Labor
Irregular contractions
No increase in intensity
Pain – confined to abdomen
Pain – relieved by walking
No cervical changes
True Labor
Contractions are regular
Increased intensity
Pain – begins lower back radiates to abdomen
Pain – intensified by walking
Cervical effacement & dilatation--Major Sx of true labor.

*Initiation of contraction---Sure Sign of labor

4. Duration of Labor
Primipara : 14 hrs & not more than 20 hrs
Multipara : 8 hrs & not > 14 hrs
* Entocia -----normal labor
*Dystocia-----difficult labor

5. Nursing Interventions in Each Stage of Labor

2 Segments of the Uterus:

1. Upper Uterine Segment: Fundus ------------------Active during labor
2. Lower Uterine Segment: Isthmus ----------------Passive during labor
*Physiologic Retraction Ring-----Boundary of the Upper & Lower Uterine Segment

A. First Stage: Onset of true contractions to full dilation & effacement of cervix.

Latent Phase:
Assessment: Dilations: 0 – 3 cm
Frequency: every 5 – 10 min
Mother: Excited, apprehensive, can communicate
Intensity: Mild
Nursing Care:
a. Encourage walking - shorten 1st stage of labor
b. Encourage to void q 2 – 3 hrs : Full bladder inhibit contractions
c. Breathing : Chest breathing

Active Phase:
Assessment: Dilations: 4 -8 cm
Frequency q 3-5 min lasting for 30 – 60 seconds
25
 Intensity: Moderate
Mother: Fears losing control of self
Nursing Care:
M – edications – have meds ready
A – ssessment include: V/S, cervical dilation & effacement, fetal monitor, etc.
D – dry lips – oral care (ointment)
dry linens
B – abdominal breathing

Transitional Phase:
Assessment: Dilations: 8 – 10 cm
Frequency q 2-3 min contractions
Durations 45 – 90 seconds
Intensity: Strong
Mother: Mood suddenly changes accompanied by hyperesthesia
*Hyperesthesia – increase sensitivity to touch, pain all over
Health Teaching :
Teach: Let father do Sacral pressure on lower back to inhibit transmission
of pain to the brain (gate theory)
Keep informed of progress
Controlled chest breathing
Nursing Care:
T – ires
I – nform of progress
R – estless support her breathing technique
E – ncourage & praise
D – iscomfort

B. Pelvic Exams
Effacement – softening & thinning of cervix. Use % in unit of measurement
Dilation – widening of cervix. Unit used is cm
*Both accomplished by uterine contractions

a. Station – relationship of the presenting unit to the ischial spine. Landmark used: Ischial Spine
-3 Station: Needs Therapeutic rest
- 2 Station: Presenting part 2 cm above ischial spine if (-) floating
- 1 station : Presenting part 1cm above ischial spine if (-) floating
0 Station: At level at ischial spine : Engagement
+ 1 station : Below 1 cm ischial spine
+3 to +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:

1. Longitudinal Lie ( Parallel) or ―Vertical‖

Cephalic - Vertex – Complete flexion

Face
Brow Poor Flexion
Chin

Breech - Complete Breech : Thigh breast on abdomen, breast lie on thigh

Incomplete Breech: Thigh rest on abdominal
Frank : Legs extend to head
Footling: Single, double
Kneeling
2. Transverse Lie (Perpendicular) or ―Horizontal‖ = Shoulder presentation.

26
c. Position – relationship of the fetal presenting part to specific quadrant of the mother‘s pelvis.
Variety:
Occipito:LOA left occipito ant (most common & favorable position)– side of maternal pelvis
LOP – left occipito posterior
LOP – most common malposition, most painful
ROP – squatting position for mother
ROT, ROA

Breech- Use sacrum (Sacro)

LSA – left sacro anterior
LST, LSP, RSA, RST, RSP
- if breech put stet above umbilicus

Shoulder/Acromniodorso
LADA, LADT, LADP, RADA

Chin / Mento
LMA, LMT, LMP, RMP, RMA, RMT, RMP

Monitoring the Contractions & Fetal heart Tone

How : Spread fingers lightly over fundus – to monitor contractions

Parts of Contractions:
Increment or Crescendo – beginning of contractions until it increases
Acme or Apex – height of contraction
Decrement or Decrescendo – from height of contractions until it decreases
Duration – beginning of 1 contraction to end of same contraction
Interval – end of 1 contraction to beginning of next contraction
Frequency – beginning of 1 contraction to beginning of next contraction
Intensity - strength of contraction

*Best time to get BP & FHT -----just after a contraction or midway of contractions

Contraction of the mother r/t blood vessel constriction

Increase BP, decrease FHT

*Placental Reserve – 60 sec o2 for fetus during contractions
Monitor that the duration of contractions should not be >60 sec
If >40 seconds, stop Oxytocin
Notify MD if >60 seconds

Health Teachings:
1.) Ok to shower: bath as necessary
2.) Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia
3.) NPO – GIT stops function during labor if with food---vomiting & aspiration---chemical neumonitis
4.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.) Sims position/side lying, 12 – 18 inch – height ofenema tubing
5.) Check FHT after administration of enema *Normal FHT: 120-160 bpm
6.) Encourage to void
7.) Perineal prep-----7 method, S position
8.) Left side-lying position to prevent supine hypotension-----Supine Vena Caval Syndrome
9.) Give analgesic ( Demerol) , Meperidine HCl---narcotic, anti-spasmodic
Given in active phase, not latent phase
No barbiturates----no antidote
S/E: Respiratory Depression
Antidote: Narcan-Naloxone---to baby only
Signs of Fetal Distress:
1.) <120 & >160
2.) Mecomium stain amnion fluid
3.) Fetal Thrushing: hyperactive fetus due to lack O2

27
 B. Second Stage: Complete dilation & effacement to birth.
“Fetal Stage”

Mechanisms of labor
1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion
Nursing Care:
- If 7 to 8 cm , multipara – bring to delivery room
- If 10 cm primipara – bring to delivery room
- Lithotomy position – put legs same time up
- A Bulging of perineum – sure sign that the baby is about to be delivered
- Teach Breathing: Pant & blow breathing, push w/ open glottis

Signs of Respiratory Alkalosis:

- Tachypnea, lighheadedness
- Tingling sensation, circumoral numbness, carpopedal spasm
DELIVERY:
- Modified Ritgens maneuver – place towel at perineum
1.)To prevent laceration
2.) Will facilitate complete flexion & extension.
- Support head & remove secretions
- Pull shoulder down & up
- Check cord, if tight---cut & clamp
- Note time of delivery
- Maintain temperature
- Put on abdomen of mother to facilitate contraction/bonding
- Clamp, do not milk. Wait for pulsation to stop then cut cord---allows 60-100cc of blood
- Proper identification-----foot printing
- Let mother see condition of baby even if dead to accept finality of death

*Amniotomy = the artificial rupture of the bag of water to facilitate delivery

EPISIOTOMY:

-Assist in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2nd stage of labor.
-Use local anesthesia or natural anesthesia or pudendal
- Ironing the perineum – to prevent laceration

2 Types:
Median Mediolateral
-Less Bleeding -More Bleeding
- Less Pain - More pain
- Easy Repair - Hard to repair
- Fast Healing - Slow to heal
- May lead to urethrouanal fistula - No major disadvantage

3 Parts Of Pelvis:

1. Inlet : AP diameter narrow, TD wider

2. Cavity : area between inlet & outlet
3. Outlet : AP wider, TD 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 & true pelvis.

28
 Nursing Care:
To prevent puerperal sepsis - < 48 hours only – vaginal pack
Bolus of Ptocin can lead to hypotension.

C. Third Stage: “ Birth To Expulsion Of Placenta”

“ Placental Stage”

*Placenta delivered from 3-10 minutes

3 Signs of Placental Separation:

1. Fundus rises – becomes firm & globular : ― Calkins Sign‖----1st sign
2. Lengthening of the cord
3. Sudden gush of blood

Types of Placental Delivery:

1. Shultz: ―Shiny‖ – begins to separate from center to edges presenting the fetal side.

2. Dunkan : ―Dirty‖ – separate from edges to center presenting maternal side – beefy red or dirty

BRANDT-ANDREW‘S MANEUVER: Slowly pull cord & wind to clamp

- Hurrying of placental delivery will lead to inversion of uterus.

Nsg. Care for the 3rd Stage:

1. Check completeness of placenta. (*Placenta has 15 – 28 cotyledons)
2. Check firmness of fundus (if relaxed, massage uterus)
3. Check BP
4. Administer Methergine IM (Methylergonovine Maleate) ―Ergotrate derivatives
S/E : HPN-----if HPN----give Oxytocin IV
5. Monitor HPN (or give oxytocin IV)
6. Check perineum for lacerations
7. Assist MD for episiorapy
8. Vaginal landscaping
9. Saline & Betadine cleansing
10. Changed Clothes
11. Flat on bed
12. Chills-d/t dehydration. Blanket
13. Let Mother sleep to regain energy
14. Recovery: Give clear liquid-tea, ginger ale, clear gelatin
15. Then Full liquid--------soft diet----regular diet------

D. Fourth Stage: The First 1-2 hours after delivery of placenta

―Recovery Stage‖

1. Maternal Observations – body system stabilizes

-Monitor V/S every 15 minutes for 1 hr
every 30 minutes for the 2nd hr
2. Check placement of Fundus at level of umbilicus.
- After delivery, fundus bet. umbilicus
- 2 hrs. after delivery---at the level of umbilicus
- If fundus above umbilicus, deviation of fundus
- Check for empty bladder to prevent uterine atony-----hemorrhage
3. Check Lochia
4. Perineum – Check for ―REEDA‖
R - edness
E- dema
E - cchemosis
D – ischarges
A – approximation of blood loss. Count pad & saturation
Fully soaked pad : 30 – 40 cc weigh pad. (1 gram=1cc)

5. Bonding – interaction between mother & newborn/ Rooming-in types

a. Straight Rooming-in baby: 24hrs with mom.
b. Partial Rooming-in: baby in morning , at night nursery

29
 Complications of Labor:

1. Dystocia: Difficult labor r/t mechanical factor

Uterine Inertia – main cause of dystocia. A sluggishness of contraction

Types:
a. Hypertonic or Primary Uterine Inertia
- Intense excessive contractions resulting to ineffective pushing
- MD administer sedative ( Valium, diazepam – muscle relaxant)
b. Hypotonic or Secondary Uterine Inertia
- Slow irregular contraction resulting to ineffective pushing
- Give oxytocin

2. Prolonged Labor : labor of more than 20 hrs. for primi, >14 hrs. for multipara d/t ineffective pushing

 Normal length of labor in primi 14 – 20 hrs & Multi 10 -14 hrs.

 Monitor baby: Fetal Distress---caput succedanum or cephal hematoma
 Maternal Effect: Exhaustion.
 Monitor contractions & FHT

3. Precipitate Labor : labor of < 3 hrs. w/ extensive lacerations--profuse bleeding---hypovolemic shock

- baby with hypoxia
S/Sx of Hypovolemic Schock:
Hypotension------late sign
Tachycardia------earliest sign + restlessness
Tachypnea
+ Cold clammy skin

Outstanding Nursing Dx: Fluid Volume Deficit

Position of mother: Modified Trendelenberg
IV – fast drip d/t Fluid Volume Deficit

4. Inversion Of The Uterus: Situation where uterus is turned inside out

S/Sx: Profuse bleeding----hypovolemic shock
Mngt: MD will push uterus back inside or not hysterectomy.

Factors Leading To Inversion Of Uterus :

a. Short cord
b. Hurrying of placental delivery
c. Ineffective fundal pressure

5. Uterine Rupture: Rupture of the uterus

Causes:
1.) Previous Classical CS----once classical, always classical
2.) Large baby
3.) Improper use of oxytocin (IV drip)
S/Sx:
1. Sudden pain
2. Profuse bleeding
3. Hypovolemic shock -----prepare for TAHBSO
* Physiologic Retraction Ring - Boundary between upper & lower uterine segment
* BANDL‘S Pathologic Ring - suprapubic depression, a sign of impending uterine rupture

6. Amniotic Fluid Embolism or Placental Embolism

- Anaphylactic Syndrome Of Pregnancy
- Amniotic fluid /fragments of placenta entered maternal circulation resulting to embolism
- Can happen to both NSD & CS

S/Sx:
1. Dyspnea
2. Chest pain
3. Frothy sputum
Prepare: Suctioning
30
 End Stage: DIC (Disseminated Intravascular Coagopathy)
- bleeding to all portions of the body – eyes, nose, etc.

7. Trial Labor
- Measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor
- Multipara: 8 – 14 hrs. & Primipara 14 – 20 hrs.

8. Preterm Labor
- Labor after 20 & before 37 wks.)

Triad S/Sx:
1. Premature contractions q 10 minutes
2. Effacement of 60 – 80%
3. Dilatation of 2-3 cm
Home Mgt:
1. CBR
2. Avoid sex
3. Empty bladder
4. Drink 3-4 glasses of water – full bladder inhibits contractions
5. Consult MD if symptoms persist

Hospital Mgt:
1. If cervix is closed 2 – 3 cm, dilation saved by administer
Tocolytic agents- halts preterm contractions.
Ex. YUTOPAR- ( Ritodrine Hcl)
S/E: Sustained tachycardia---antidote---Propanolol (Magnesium Sulfate)
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles – notify MD – pulmonary edema
– administer oral yutopar 30 minutes before d/c IV

2. If cervis dilated >4 cm----cannot save the baby

3. If cervix is open – MD – steroid dextamethzone (betamethazone)

to facilitate surfactant maturation preventing RDS

4. If Preterm delivery: Cut cord ASAP to prevent jaundice or hyperbilirubenia.

IX. Postpartal Period: “ 5th Stage Of Labor‖

A. Puerperium : Covers 1st 6 wks. Post-delivery

-Incourage early ambulation to prevent Hyperfibrinogenia ----prone to thrombus formation

B. Involution : Return of reproductive organ to its non pregnant state.

Principles underlying puerperium

I. To return to Normal & Facilitate healing

a. Physiologic Changes

1. Systemic Changes

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 & thus adding to the workload of the heart. This is critical
especially to gravidocardiac mothers.

- After 24 hrs.-----Normal increase WBC up to 30,000 cumm (Normal WBC: 10,000- 15,000 mm)

Monitor:
1. Increase plasma volume to 1,500 cc
2. Sudden decrease in BP
3. Elevated WBC up to 30,000 um
31
 4. Increase temperature w/n the 1st 24 hr. post-partum is normal
After 24 hrs.----a sign of infection
5. Foul-smelling lochia ----a sign of infection
6. V/S every 15 minutes, every 30 minutes 2 hrs. after
7. Hyperfibrinogenia
8. Orthostatic hypotension

Genital Tract
a. Cervix - Check cervical opening
b. Vaginal & Pelvic Floor

c. Uterus
- Return to normal 6 – 8 wks.
-Fundus goes down 1 finger breath/day until 10th day – no longer palpable already
behind symphisis pubis

*Subinvolution of the uterus:

-3 days after post partum, delayed healing of uterus w/ big clots of blood- a medium
for bacterial growth- (puerperal sepsis)
Mgt: D&C

*After birth pains are normal----for multiparous----breastfeeding

Mngt:
1. Position prone
2. Cold compress – to prevent bleeding
3. Mefenamic acid

d. Lochia
Components of WBC: blood, WBC, deciduas, bacteria, microorganism.
Both NSD & CS with lochia.

1. Ruba : Red - 1st 3 days present, musty/mousy, moderate amount

2. Serosa : Pink to brown - 4 to 9th day, limited amount
( 4,5,6 –pink & 7,8,9---brown)
3. Alba : Créme white - 10 to 21 days or 3 wks. Very decreased amt

Urinary Tract:

Bladder : Frequency in urination after delivery d/t urinary retention with overflow
Dysuria Post-Partum---cause by damage to the trigone of the bladder
Mgt:
1. Urine collection
2. Alternate warm & cold compress
3. Stimulate bladder
Colon:
Constipation d/t NPO, fear of bearing down of tearing laceration

Perineal Area:
Lateral Sims position for painful perineum
For episiotomy site: Cold compress if (+) pain post-delivery followed by warm compress
After 24 hrs. recommend hot sitz bath, not compress
Sex- when perineum has healed

II. Provide Emotional Support (Reva Rubia Theory)

1. Psychological Responses:

a. Taking In Phase: ― Dependent Phase‖

(1st three days)
Mother : Passive, cannot make decisions
Tells child birth experiences
Focus HT: Proper Hygiene

32
 b. Taking Hold Phase:
― Dependent to Independent Phase‖
- 4 to 7 days
- Mother: Active, can make decisions
- Focus HT: Care of newborn & Family Planning Method

*Post-Partum Blues/ Baby Blues

- Present 4 – 5 days (50-80% incidence rate)
- Overwhelming feeling of depression characterized by crying, despondence &
inability to sleep & lack of appetite.

d/t sudden hormonal changes---– let mom cry – therapeutic.

May lead to Post-Partum Psychosis

c. Letting Go Phase:
- ―Interdependent Phase‖
- 7 days & above
- Mother redefines new roles as parents may extend until child grows.

III. Prevent complications

1. Hemorrhage : Bleeding of > 500cc

- Most common complicattions
- CS lost of blood 600 – 800 cc normal
- NSD normal loss of 500 cc blood

A. Early Postpartum Hemorrhage:

- Bleeding w/n 1st 24 hrs post-partum

1. Uterine Atony
S/Sx:
- Baggy or relaxed uterus
- Profuse bleeding
Complications: Hypovolemic shock
Mgt:
1.) Massage uterus only if w/ uterine atony until contracted
2.) Cold compress
3.) Modified trendelenberg
4.) IV fast drip/ oxytocin IV drip
5.)Breastfeeding for sucking--- PPG will release oxytocin so uterus will contract.

2. Lacerations

S/Sx:
- Well-contracted uterus
- Profuse bleeding
- Assess perineum for laceration
- Degree of laceration
- Mgt: Episiorapy

Types: 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

3. Disseminated Intravascular Coagulopathy (DIC)

-Consumption of pregnancy or Hypofibrinogen- failure to coagulate
- Bleeding to any part of body (eyes, ears)
- Results to stillbirth or abruptio placenta

Mgt: BT- cryoprecipitate or fresh frozen plasma

-Hysterectomy

33
 4. Hematoma
- Bluish or purple discoloration of SQ tissue of vagina or perineum.
- Candidate if there is too much manipulation
- Delivery of very large baby
- Pudendal anesthesia
Mgt:
- Cold compress q 10-20 minutes with rest period of 30 minutes for 24 hrs
- Shave
- Incision on site, scraping & suturing

B. Late Postpartum Hemorrhage

- Bleeding after 24 hrs

1. Retained Placental Fragments

Mgt:
- D&C or manual extraction of fragments & massaging of uterus.
- D&C except in 3 cases:

a. Placenta Acreta – attached placenta to myometrium. Hysterectomy

b. Placenta Increta – deeper attachment of placenta to myometrium - Grand multiparous

c. Placenta Percreta – invasion of placenta to perimetrium -Post CS

2. Infection

Sources of infection:
a. Endogenous – from within body
b. Exogenous – from outside

Causes:
a. Anaerobic streptococci – most common - from members HT
b. Unhealthy sexual practices

General Signs of Infection:

a. Inflammation : Calor (heat), Rubor (red), Dolor (pain) Tumor(swelling)
b. Purulent discharges
c. Fever
d. Loss of function

General Mgt:
a. Supportive care: CBR, hydration, TSB, cold compress, analgesic, Vit. C
b. Culture & sensitivity – for antibiotic—shld be taken on time
prolonged use of antibiotic lead to superinfection Ex. fungal infection

Types of Infection:

a. Perineal Infection
-general signs + 2-3 stitches of dislodge w/ purulent discharcge
Mgt:
Removal of sutures & drainage, saline

b. Endometriosis/endomitritis
- general signs + Inflammation of endometrial lining + addominal tenderness
Mgt:
Fowler‘s Position to facilitate drainage & localize infection
Oxytocin & antibiotic

c. Thrombophelibitis

34
IV. Motivate The Use Of Family Planning

Principles:
1.) Determine one‘s own beliefs 1st
2.) Never advice a permanent method of planning
3.) Method of choice is an individual choice.
4.) Informed Consent

1. Natural Method – the only method accepted by the Catholic Church

a. Billings / Cervical Mucus:

- Test for Spinnbarkeit & Ferning Pattern (Estrogen)
- Peak 13th day: clear, watery, stretchable, elastic (10-15 cm) long spinnbarkeit

b. Basal Body Temperature

- 13th day temperature goes down before ovulation & on 14th & 15th day
- Progesterone responsible for temp. changes
- No sex
- Get before arising in bed

c. LAM (Lactation Amenorrheal Method)

- Prolactin : Hormone that inhibits ovulation especially in:
Breast feeding- menstruation will come out 4 – 6 months
If bottle fed 2 – 3 months
- Disadvantage of Lam – might get pregnant

d. Symptothermal
- Combination of BBT & cervical.
- Most effective natural method

2. Social Method

a. Coitus Interuptus/ Withdrawal

- Least effective method
- With ejaculation

b. Coitus Reservatus : Sex without ejaculation

c. Coitus Interfemora : ―ipit‖- to hold
d. Calendar Method
- Count 14 days before next menstruation (ovulation)
e. Origoknause Formula :
- Monitor cycle for 1 year. Get shortest & longest cycle from Jan – Dec
Ex. shortest – 18
longest – 11
June 26 Dec 33
- 18 -11
8 - 22 unsafe days

3. Physiologic Method:

a. Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland
production of FSH & LH w/c are essential for the maturation & rupture of a follicle.
- 99.9% effective.
- Waiting time to become pregnant- 3 months.
- Consult OB-6mos.

Adverse Effects: Breakthrough Bleeding

Contraindications:
-Chain Smoking
- HPN
- DM
- Heart Disease
- Extreme obesity
- Thrombophlebitis
- Problems in clotting factors
35
Alerts on Oral Contraceptive:

- In case a mother who is taking an oral contraceptive for a long time plans to have a baby, she would
wait for at least 3 months before attempting to conceive to provide time for the estrogen &
progesterone levels to return to normal.

- If a new oral contraceptive is prescribed the mother should continue taking the previously prescribed
contraceptive & 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 & subarachnoid hemorrhage.

21 day pill- start 5th day of mens

28day pill- start 1st day of mens
missed 1 pill – take 2 next day

Side Effects of Oral Contraceptive: Immediate Discontinuation----HPN

A – abdominal pain
C – chest pain
H - headache
E – eye problems
S – severe leg cramps

*If mother taking pills & there‘s increase in BP ----stop 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.

b. DMPA :
- Depomedroxy Progesterone Acetate (Depo-proveda)
- Inhibits ovulation: has progesterone inhibits LH
- IM q 3 months
- Never massage injected site, may lessen the duration of effectivity

c. Norplant
- Composed of 6 match sticks – like capsules implanted subdermally containing progesterone.
- Good for 5 yrs – disadvantage if keloid skin
- As soon as removed – can become pregnant

4. Mechanism & Chemical Barriers

a. Intrauterine Device (IUD)

Action: Prevents implantation by altering the motility of sperm & ovum

Alerts:
-Right time to insert is after delivery or during menstruation
- Primary indication for use of IUD : Parity or # of children, if 1 kid only don‘t use IUD
-Most common complication: Excessive Menstrual Flow & Expulsion of the device
- 99.7% effective.
- Does not give protection against Syphilis

Others:
P-eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A -bdominal pain or pain with intercourse
I - nfection (abnormal vaginal discharge)
N -ot feeling well, fever, chills
S - trings lost, shorter or longer

Other Side Effects:

a. Uterine inflammation
b. Uterine perforation
c. Ectopic pregnancy
36
 HT:
a. Check for string daily
b. Monthly checkup
c. Regular pap smear

b. Condom :
- Made of Latex inserted to erected penis or lubricated vagina
- Prevents the sperm to enter the uterus
Alerts:
Disadvantage:
It lessen sexual satisfaction
It gives higher protection in the prevention of STDs
Highest protection against STDs----Female condom

c. Diaphragm
- Rubberized dome-shaped material inserted to cervix preventing sperm to get to the uterus.

Alerts:
-Reusable
- Keep in place 6-8 hrs. after intercourse
- Contraindication: UTI
HT:
1.) Proper hygiene
2.) Check for holes before use
3.) Must stay in place 6 – 8 hrs after sex
4.) Must be refitted especially if w/ weight change of 15 lbs

d. Cervical Cap
-More durable than diaphragm
- No need to reapply spermicide
- Could stay for more than 24 hrs.
C/I: Abnormal Pap Smear

e. Foams, Jellies, Creams

- Spermicide (Non- oxynol-9)
- Foams (most effective spermicide)
- Jellies, creams
S/E: Toxic Shock Syndrome

5. Surgical Method

a. Bilateral Tubal Ligation (BTL)

- Done at the isthmus
- can be reversed 20% chance depending on type of operation
- Can take effect immediately
HT: Avoid lifting heavy objects

b. Vasectomy
- Cut at the vas deferense.
- >30 ejaculations before safe sex
- O – zero sperm count for at least 2 (-) results

XI. High Risk Pregnancy

1. Hemorrhagic Disorders

General Management:
1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
4.) Prepare mother for ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Assess for bleeding: approximation
7.) Save discharges for histopathology : To determine if product of conception has been expelled
or not

37
 A. First Trimester Bleeding:

1. Abortions : Termination of pregnancy before age of viability (before 20 weeks)

a. Spontaneous Abortion: or “Miscarriage‖

Cause:
1.) Chromosomal aberrations
2.) Blighted ovum
3.) Germ Plasma Effect
*Termination after age of viability: Fetal Demise/Stillbirth
Classifications:

1. Threatened : Pregnancy is jeopardized by bleeding & cramping but

the cervix is closed
- Pregnancy can be saved

2. Inevitable : Moderate bleeding, cramping, tissue protrudes from the cervix

(Cervical dilation)
- Cannot save the baby
Types:

a. Complete: All products of conception are expelled.

No mgt just emotional support!
b. Incomplete : Placental & membranes retained.
Mgt: D&C
c. Habitual –: 3 or more consecutive pregnancies result in abortion usually
related to incompetent cervix.
Present 2nd trimester
Incompetent cervix – abortion
Surgery For Habitual Abortion:

1. McDonalds Procedure: Temporary circlage on cervix. For NSD

Common Complications:
a. Signs of infection
b. Signs of labor
During delivery, circlage is removed. NSD
2. Shirodkar Procedure/Sheridan: Permanent surgery cervix.
CS required.

d. Missed: Fetus dies; product of conception remain in uterus 4 weeks or longer.

Signs of pregnancy cease
(-) Pregnancy Test
Scanty, dark brown bleeding
Mgt: Induced labor by oxytocin or vacuum extraction

b. Induced Abortion
Therapeutic abortion to save life of mother.
Double effect choose between lesser evil.

2. Ectopic Pregnancy
- Occurs when gestation is located outside the uterine cavity.
- Common site: Tubal or Ampular
- Dangerous site - interstitial
Unruptured Tubal rupture
1. Missed period 1. Sudden , sharp, severe pain. Unilateral radiating to shoulder.
2. Abdominal pain w/n 3 -5 wks of missed period 2. Shoulder pain (indicative of intraperitoneal bleeding that
(maybe generalized or one sided) extends to diaphragm & phrenic nerve)
3. Scant, dark brown, vaginal bleeding Pain occurs at site of ectopic preg.
4. Vague discomfort 3. (+) Cullen‘s Sign : bluish tinged umbilicus
Nursing Care: – signifies intra peritoneal bleeding
-V/S 4. Syncope (fainting)
- Administer IV fluids, Montir I & O Mgt: Surgery depending on site
- Monitor for vaginal bleeding Ovary: oophrectomy
- Prepare for culdocentesis: To determine Uterus : hysterectomy
hemoperitoneum
- Nonsurgical: Methotraxate
38
B. 2nd Trimester Bleeding

1. Hydatidiform Mole /―bunch or grapes‖/ ―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 from the swelling of the chronic villi & 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.
-Cause: Idiopathic
Use: Methotrexate to prevent choriocarcinoma

Assessment:

Early Signs - Vesicles passed thru the vagina

Hyperemesis gravidarium d/t increase HCG
Fundal height rapidly increase
Vaginal bleeding( scant or profuse)
Early in Pregnancy
High levels of HCG------hyperemesis
Pre-eclampsia at about 12 wks

Late Signs Hypertension before 20th wk

Vesicles look like a ― snowstorm‖ on sonogram
Anemia
Abdominal cramping

Serious Complications Hyperthyroidism

Pulmonary embolus
Nursing Care:
Prepare for D&C
Do not give oxytoxic drugs----contraction will lead to pulmonary embolism

Health Teachings:
a. Return for pelvic exams as scheduled for one year to monitor HCG &
assess for enlarged uterus & rising titer indicative of choriocarcinoma
b. Avoid pregnancy for at least one year

2. Incompetent Cervix
- premature/early dilatation of cervix (18 wks.)
Factors:
a. Hormonal Imbalance
b. Abnormal Cervix

C. 3rd Trimester Bleeding /“Placenta Anomalies”

1. 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
3 Types:
a. Marginal
b. Partial
c. Complete
Assessment:
- Frank , bright red, painless bleeding ------Most Outstanding Sign
- Engagement (usually has not occurred)
- Fetal distress
- Presentation ( usually abnormal)
Dx:
- Diagnosed by ultrasound

Most Common Complication: Sudden Fetal Blood Loss

39
 Nursing Care:
- Bedrest-------initiate NPO-----candidate for CS
- Prepare to induce if cervix is ripe
- Administer IV
- Avoid IE, sex or enema – may lead to sudden fetal blood loss
- Double set up------informed consent---surgeon responsible & explain
------delivery room may be converted to OR
Surgeon – in charge of sign consent, RN as witness
MD explain to patient
2. Abruptio Placenta

- It is the premature separation of the placenta from the implantation site

- It usually occurs after the 20th week of pregnancy

Outstanding Sx: Dark red, painful vaginal bleeding, board like or rigid uterus.

Assessment:
Concealed bleeding (retroplacental)---inside—palpate a board-like abdomen
Couvelaire uterus (caused by bleeding into the myometrium)
(-) contraction of uterus d/t hemorrhage (uterine apoplexy)
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
Placenta Previa & Vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type & crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report S/S of DIC
Monitor v/s for shock
Strict I&O
*Dangerous Sign-------DIC----prepare for hysterectomy

3. Placenta Succenturiata: 1 or 2 more lobes connected to the placenta by a blood vessel may lead
to retained placental fragments if vessel is cut.

4. Placenta Circumvalata: Fetal side of placenta covered by chorion

5. Placenta Marginata : Fold side of chorion reaches just to the edge of placenta

6. Battledore Placenta : Cord inserted marginally rather then centrally

7. Placenta Bipartita: Placenta divides into 2 lobes

8. Vilamentous Insertion of cord : Cord divides into small vessels before it enters the placenta
9. Vasa Previa : Velamentous insertion of cord has implanted in cervical OS

D. Hypertensive Disorders

1. Pregnancy Induced Hypertension (PIH)

HPN after 24 wks of pregnancy, resolved 6 weeks post partum.
3 Types:
1.) Gestational Hypertension: HPN w/o edema & protenuria H without EP
2.) Pre-eclampsia : HPN w/ edema & protenuria or albuminuria HE P/A
3.) HELLP Syndrome: Hemolysis w/ Elevated Liver enzymes & Low Platelet count

Triad Signs of Pre-eclampsia: HEP/A

*Earliest Sign of Pre-eclampsia: Increase weight or inability to wear wedding ring

40
2. Transitional Hypertension
HPN between 20 – 24 wks & after that no more

3. Chronic or Pre-existing Hypertension

HPN before 20 wks not solved 6 weeks post partum.

Causes:
a. Idiopathic (unknown but multi-factorial)
b. Common in primis d/t 1st exposure to chorionic villi
c. Common in multiple pregnancy d/t increase exposure to chorionic villi
d. Mother w/ low socio-economic status d/t low intake of CHON
e. Teenager moms d/t/ low compliance

3 Types Of Pre-Eclampsia:

1.) *Mild Preeclampsia

a.) Increase weight gain d/t edema
b.) BP 140/90
c.) Protenuria +1 to +2

2.) Severe Preeclampsia

a. BP 160/110
b. Protenuria +3 to +4

Signs Present:

- Cerebral & visual disturbances

- Epigastric pain d/t liver edema
- Oliguria usually indicates an impending convulsion.

3.) Eclampsia
- With seizure!
- Increase BUN d/t glomerular damage & decrease CO2 combining power
- Provide safety.

Nursing Care:

P – romote bed rest to decrease O2 demand & facilitate Na excretion.

Water immersion will cause to urinate.

P- prevent convulsions by nursing measures or seizure precaution

1.) Dimly lit room . Quiet calm environment----put pt. acroos nursing station
2.) Minimal handling ---– planning procedure
3.) Avoid jarring bed

P- prepare the following at bedside

- Tongue depressor before seizure ( aura of epigastric pain)
- Turning to side done AFTER seizure! Observe only! for safely.
- Suction, O2 machine

E – ensure high protein intake ( 1g/kg/day)

- Na – in moderation
A – anti-hypertensive drug Hydralazine ( Apresoline)

C –NS depressant ( Mg So4 ) anti-convulsant -----efffect---absence of seizure

Action: Vasodilatation, Cathartic
E – valuate physical parameters for Magnesium sulfate (Stock: Ampule 10cc)

Magnesium SO4 Toxicity:

a.BP decrease
b. Urine output decrease (<30 cc/hr)
c. Respiration < 12
d. Patella reflex absent – 1st sign Mg SO4 toxicity.
Antidote – Ca gluconate
41
 PATHOPHYSIOLGY OF HYPERTENSION

Related to sensitivity to Angiotensin II--------causes Vasoconstriction

Peripheral & Vascular Vasospasm

O2 supply --------HPN

Kidney Liver Eyes Placenta

O2 O2 O2 O2

Glomerules GFR Tissue Ischemia Retinal Vasoconstriction Placental Degeneration

Degenerate

Permeability Na Reabsoption Liver Edema Blurred Vision IUGR

leads to

Protenuria H2O retention Epigastric pain Scotoma Pre-term birth

(urine) (fetal distress)

Fluid shift Results to Edema But reversible blindness

ICF ---ECF (generalized edema) a
(Anasarca) u
r
a

o
Pulmonary Edema f
Leads to
More CHF I
m
Cerebral Edema p
e
n
Cerebral Compression d
i
n
Cerebral Irritability g
Convulsion

CONVULSION

42
E. Diabetes Mellitus

- Absence or lack of insufficient insulin (Insulin produced in the Islet of Langerhans of pancreas)
Function of insulin : Facilitates transport of glucose to cell

Dx: 1 hr 50gr Glucose Tolerance Test (GTT)

Normal Glucose: 80 – 120 mg/dl < 80: Hypoglycemic

(Euglycemia) > 120: Hyperglycemia
If >130 mg/dl, the mother needs to undergo 3 hr. GTT

Maternal Effect DM:

1.) Hypoglycemia – 1st trimester d/t developing brain of fetus

2.) Hyperglycemia – 2nd & 3rd Trimester d/t HPL (human placental lactogen- a diabetogenic effect)
3.) Frequent infection: Moniliasis (DM = Increase cholesterol)
4.) Polyhydramnios : >1,500 cc
5.) Dystocia: Difficult birth d/t abnormalities in fetus or mom.

Insulin Requirement of Mother during Pregnancy:

- Decrease in insulin by 33% in 1st trimester

- 50% increase insulin at 2nd – 3rd trimester.
- Post partum decrease 25% due placenta out.

Fetal Effect DM:

1.) Hyperglycemia & hypoglycemia

2.) Macrosomia (large gestational age) baby delivered > 400g or 4kg
3.) Preterm birth to prevent stillbirth
4.) IUGR

Newborn Effect : DM
1.) Hyperinsulinism (1st)
2.) Hypoglycemia (<40mg/dl)

- Normal glucose in newborn (45 – 55 mg/dL)

- Heel Stick Test – get blood at heel

Sx of Hpoglycemia:
 High pitch shrill cry
 Tremors
 Jitteriness

N.I. – Monitor glucose thru heel stick test

- Administer dextrose
- Decrease H2o may lead to cerebral plasy

3.) Hypocalcemia ( < 7mg%)

Sx:
 Calcemia tetany
 Trousseau Sign
Tx: Give calcium gluconate if decrease calcium

43
 F. Heart Disease

Classifications:
*Mother with RHD at childhood

Class I – No limitation of physical activity

Class II –Slight limitation of activity

- Ordinary activity causes fatigue & discomfort.

Recommendation of Class I & II

1. Sleep 10 hrs a day
2. Rest of 30 minutes & after meal
3. Class I & II: Good progress for vaginal delivery

Class III - Moderate limitation of physical activity.

- Less than ordinary activity causes discomfort

Recommendation:
1.) Early hospitalization by 7-8 months

Class IV - Marked limitation of physical activity.

- Even at rest there is fatigue & discomfort.
Recommendation:
a. Therapeutic abortion
b. If pushes through with pregnancy
1.) Antibiotic Therapy - To prevent subacute bacterial endocarditis
2.) Anticoagulant : Heparin doesn‘t cross placenta
c. Class III & IV: Poor prognosis for vaginal delivery, not CS!
During Delivery:
a. NOT lithotomy! High semi-fowlers during delivery.
b. No valsalva maneuver ---may trigger cardiac arrest
c. Left side-lying position
d. VD with regular anesthesia
e. Low forcep delivery d/t inability to push.
f. It will shorten 2nd stage of labor.
----episiotomy
----fundal pressure
----forcep delivery

XII. Intrapartal Complications

1. Cesarean Delivery
Indications:
a. Multiple gestation
b. Diabetes
c. Active herpes II
d. Severe toxemia
e. Placenta previa
f. Abruptio placenta
g. Prolapse of the cord
h. CPD -------------------Primary indication for CS
i. Breech presentation
j. Transverse lie

CS Indication for Multiple Gestation:

2 Types:
1. Monozygotic
- Identical Twins (same sex, characteristics, physical & IQ, attitude)
- 1 ovum, 1 sperm, 1 chorion, 2 amnions

1 placenta 2 separate amniotic fluid

2. Dizygotic
- Fraternal twins
- May have the same or opposite sex
- 2 ovum, 2 sperm, 2 chorion, 2 amnions
44
 Procedure:
a. Classical : Vertical Incision. Once classical always classical
b. Low Segment: Bikini line type – For aesthetic use
VBAC: Vaginal birth after CS

2. INFERTILITY
- Inability to achieve pregnancy within a year of attempt
- Manageable

a. Sterility : Irreversible
b. Impotency: Inability to have an erection

2 Types Of Infertility
1.) Primary – no pregnancy at all
2.) Secondary – not able to become pregnant following 1st pregnancy

Infertility Test:

A. Test male 1st

- More practical & less complicated
- Need: sperm only
- Put sperm in sterile bottle container ( not plastic has chem.)
- If longer test. Put in axilla
2. Sperm Count:
- 3-5 ml
- 20 to 120 million/cc sperm
- 60 to 600 m/cc per ejaculation
Sperm motility: Least criterion to determine fertility
*Azoospermia – no single sperm---at risk are chain smokers

3. Sims-Huhner Test/ Post-coital Test

- Procedure: Sex 2 hrs before test
- Female remains supine 15 min after ejaculation
- Cervical mucus is tested
*Normal: Cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If >15 – low sperm count
Factors: Low Sperm Count
1.) Occupation- truck driver
2.) Chain smoker
Mgt:
1. Rx: Clomid ( Clomiphine Citrate) to induce spermatogenesis

2. GIFT (Gamete IntraFallopian Transfer)

-For low sperm count
- Sperm put directly in the fallopian tube (ampula) via surgery
3. IVF – Invitro Fertilization
last recourse (successful 1 st in England)
B. Female Test

1.) Anovulation :
- No ovulation
- Most common problem d/t increase prolactin – hyperprolactinemia

Rx: 1. Administer Parlodel ( Bromocryptine Mesylate)

Action: Anti-hyperprolactineuria

2. Give mom Clomid:

Action: To induce oogenesis or ovulation
S/E: Multiple Pregnancy
2.) Tubal Occlusion
- Tubal blockage
Hx:
 Previous infection
 PID that has scarred tubes
 Use of IUD leading to perforation
 Ruptured Appendix (burst) leading to peritonitis & scarring

45
  STD leading to PID

Dx:
Hysterosalphingography:
-Used to determine tubal patency with use of radiopaque material

46
 BASIC GENETICS & OBSTETRICS

I. PRINCIPLES

1. Alleles
- Refers to the different variations of a trait. Ex. Different eye color or hair color

2. Genes are Dominant or Recessive for a trait:

a. Dominant gene in a pair is expressed even if the other gene is different

b. Recessive gene for a trait is only expressed if the other gene in the pair is the same-recessive

3. GENOTYPE
- Refers to an individual‘s entire genetic make-up created when an ovum & sperm unite at fertilization

4. PHENOTYPE
- Refers to an individuals physical appearance that results from the manner in w/c his genotype is expressed

5. KARYOTYPE
- Photograph of an individual‘s chromosome used to diagnosed chromosomal aberrations

II. TRANSMISSION OF DEFECTIVE GENES

1. UNIFACTORIAL (single gene) INHERITANCE

- Defect is controlled by 1 gene as a result of transmission patterns

a. AUTOSOMAL DOMINANT INHERITANCE

- Defected gene is dominant, defected gene is always expressed even if the other gene is normal

Criteria:
 If 1 parent is affected & the other is normal = 50% chance in each pregnancy that baby is affected
= 50% chance in each pregnancy that baby is normal

MENDELIAN LAW
Ex.
Father Huntington’s Chorea
Retinoblastoma
Mother 25 25 Polydactyly
Achondroplasia (dwarfism)
25 25
Normal Gene: N (capital letter)
Defected Gene: d (small letter)

b. AUTOSOMAL RECESSIVE INHERITANCE

- Defected gene is recessive, only expressed if the other pair of gene is also a defected recessive gene

Criteria:
 If 2nd gene is normal, abnormality is not expressed but the person is a carrier of the defected gene
w/ can be transmitted to offspring.
 2 carriers of the recessive genes must each contribute for the abnormality to be expressed in the
baby.
Ex.
 For each pregnancy: Cyctic Fibrosis
Sickle Cell Anemia
= 25 % chance that the baby is affected Galactosemia
= 25 % chance the baby is not affected Celiac Disease
= 50 % baby is a carrier Phenylketonuria (PKU)
Tay-sachs Disease

47
c. X – LINKED RECESSIVE INHERITANCE

- Defective gene is carried on the X chromosome

Ex.
Criteria:
Hemophilia
 Dominant Carrier = Women Color Blindness
Duchenne’s Muscular Dystrophy
Son

Daughter

Son
 Males severely affected when they receive the recessive gene from their mother since there is no
corresponding gene on their Y chromosome. Can only transmit to their female offspring
 Females only express the disorder if they receive a recessive gene from mother & affected father

d. INBORN ERRORS OF METABOLISM

- Problems R/T absence or defect in enzyme responsible for metabolism of protein, fat or carbohydrate
leading to an accumulation of harmful substance (phenylalanine) or absence of a substance (thyroxine).

Criteria:
 Follows an autosomal recessive pattern of inheritance
 Physical & mental development severely affected as child grows older
 Multifactorial inheritance:

- Expression of abnormality occurs if required # of defective genes are

transmitted
- Less than required genes are transmitted but environmental factors are present
- Family x present

Ex.
Cleft lip palate
Neural tube defects
Pyloric Stenosis
Congenital Heart Defects

e. X- LINKED DOMINANT INHERITANCE

- Defected gene carried on the X chromosome but is dominant & expressed in both male & female
offspring who inherit the defected gene

Criteria:
 Males severely affected Ex.
Ricketts

48