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Ob 1 1
Ob 1 1
A. Mons pubis or mons veneris – pad of fat which lies over the symphysis
pubis covered by skin and at puberty by short hairs; protects the
surrounding delicate tissues from trauma.
B. Labia majora – two folds of skin with fat underneath; contain Bartholin’s
glands which are believed to secrete a yellowish mucus which acts as a
lubricant during sexual intercourse. The openings of the Bartholin;s glands
are located posteriorly on either side of the vaginal orifice.
C. Labia minora – two thin folds of delicate tissues; form an upper fold
encircling the clitoris )called the prepuce) and unite posteriorly (called the
fourchette) which is highly sensitive to manipulation and trauma that is
why it is often torn during a woman’s delivery.
D. Glans clitoris - small erectile structure at the anterior junction of the labia
minora, which is comparable to the penis in its being extremely sensitive.
E. Vestibule – narrow speace seen when the labia minora are separated.
F. Urethral meatus – external opening of the urethra: slightly behind and to
the side are the openings of the Skene’s glands (which are often involved in
infections of the external genitalia).
G. Vaginal orifice or Introitus – external opening of the vagina covered by a
thin membrance (called hymen) in virgins.
H. Perinuem – area from the lower border of the vaginal orifice to the anus;
contains the muscles (e.g., pubococcoygeal and levator ani muscles) which
support the pelvic organs, the arteries that supply blood to the external
genitalia and the pudendal nerves which are important during delivery
under anesthesia.
C. Fallopian Tubes – 4 inches long from each side of the fundus; widest part
(called ampulla) spreadsinto fingerlike projections (called fimbriae).
Responsible for transport of mature ovum from ovary to uterus; fertilization
takes place in its outer third or outer half.
D. Ovaries – almond-shaped, dull white sex glands near the fimbriae, kept in
plact by ligaments. Produce, mature and expel ova and manufacture
estrogen and progesterone.
III. THE PELVIS (Figure 3) – although not a part of the female reproductive system
but of the skeletal system, it is a very important body part of pregnant women.
A. Structure
1. Two os coxae/innominate bones – made up of:
1.1 Ilium – upper extended part; curved upper border is the
iliac crest.
1.2 Ischium – under part; when sitting, the body rests on the
ischial tuberosities; ischial spines are important
landmarks.
1.3 Pubes – front part; join to form an articulation of the pelvis
called the symphysis pubis.
2. Sacrum – wedge-shaped, forms the back part of the pelvis.
Consists of 5 fused vertebrae, the first having a prominent upper
margin called the sacral promontory.
3. Coccyx – lowest part of the spine; degree of movement between
sacrum and coccyx made possible by the third articulation of the
pelvis called sacroccygeal joint which allows room for delivery of
the fetal head.
B. Divisions – set apart by the linea terminalis, an imaginary line from the
sacral promontory to the ilia on both sides to the superior portion of the
symphysis pubis.
1. False pelvis – superior half formed by the ilia. Offers landmarks
for pelvic measurements; supports the growing uterus during
pregnancy; and directs the fetus into the true pelvis near the end
of gestation.
2. True pelvis – inferior half formed by the pubes in front, the iliac
and the ischia on the sides and the sacrum and coccyx behind.
Made up of three parts:
2.1 Inlet – entranceway to the true pelvis. Its transverse
diameter is wider than its anterosposteior diameter. Thus:
2.1.1 Transverse diameter = 13.5 cm.
2.1.2 Anteroposterior diameter (AP) = 11 cm.
2.1.3 Right and left oblique diameter = 12.75 cm.
2.2 Cavity – space between the inlet and the outlet. Contains the
bladder and the rectum, with the uterus between them in an
anteflexed position towards the bladder.
2.3 Outlet – inferior portion of the pelvis, bounded on the back
by the coccyx, on the sides by the ischial tuberosities and in
front by the inferior aspect of the symphysis pubis and the
pubic arch. Its AP diameter is wider than its transverse
diameter.
C. Types/Variations
1. Gynecoid – “normal” female pelvis. Inlet is well rounded forward
and back. Most ideal for childbirth.
2. Anthropoid – transverse diameter is narrow, AP diameter is lager
than normal.
3. Platypelloid – inlet is oval, AP diameter is shallow
4. Android – “male” pelvis. Intel has a narrow, shallow posterior
portion and pointed anterior portion.
D. Measurements
1. External – suggestive only of pelvic size:
1.1 Intercristal diameter – distance between the middle points of
the iliac crests.
Average = 28 cm.
1.2 Interspinous diameter – distance between the anterosuperior
iliac spines.
Average = 25 cm.
1.3 Intertrochanteric diameter – distance between the
trochanters of the femur.
Average = 31 cm.
1.4 External conjugate/Baudelocque’s diameter – distance
between the anterior aspect of the symphysis pubis and
depression below L5. Average = 18-20 cm.
HUMAN SEXUALITY
I. DEFINITION OF TERMS
A. Puberty – encompasses the physiologic changes leading to the
development of adult reproductive capacity; the process includes
maturation of the hypothalamus, pituitary gland and gonads. The role
of the anterior pituitary gland. The pituitary secretion of
gonadotropin initiates growth and maturation. It occurs initially
during sleep and later in puberty throughout wakefulness.
B. Adolescence – encompasses the physiologic, social, and cognitive
changes leading to the development of adult identity. The process
includes individual, achievement of personal independence and
maturation of cognitive reasoning skills.
C. Thelarche – budding of the breasts
D. Adrenarche – development of axillary and pubic hair
A. Excitement
1. Vaginal lubrication and vasocongestion of the genitalia.
2. Penile erection due to vasocongestion
B. Plateau
1. Formation of orgasmic platform due to prominent
vasocongestion.
2. Generalized muscle tension, hyperventilation, increased BP,
tachycardia in the late plateau phase.
3. Pre-ejaculatory phase with live spermatozoa
C. Orgasmic
1. Strong rhythmic contractions of vagina and uterus.
2. In males, vas deferens, seminal vesicle, ejaculatory duct and
prostate contract 3-4 times over a few seconds causing pooling of
seminal fluid in the prostatic urethra. Rhythmic contractions in
males occur at 0.8 seconds interval that assist in the propulsion
process
D. Resolution – rapid decline in pelvic vasocongestion. All organs return
to previous position
E. Refractory phase – only in males; the period during which no amount
of stimulation can cause another erection. Not manifested in females
because females are multi-orgasmic. This phase lengthens with age.
PREGNANCY AND PRENATAL CARE
I. FERTILIZATION
A. Definition: the union of the sperm and the mature ovum in the outer
third or outer half of the Fallopian tube.
B. General considerations
1. Normal amount of semen per ejaculation = 3-5 cc. = 1 teaspoon.
2. Number of sperms in an ejaculate = 120-150 million/cc
3. Mature ovum is capable of being fertilized for 12-24 hours after
ovulation. Sperms are capable of fertilizing even for 3-4 days after
ejaculation.
4. Normal life span of sperms = 7 days
5. Sperms, once deposited in the vagina, will generally reach the cervix
within 90 seconds after deposition.
6. Reproductive cells, during gametogenosis, divide by meiosis
(haploid umber of daughter cells); therefore, they contain only 23
chromosomes (the rest of the body cells contain 46 chromosomes).
Sperms have 22 autosomes and 1 X sex chromosome or 1 Y sex
chromosome. The union of an X-carrying sperm and mature ovum
results in a baby girl (XX); the union of a Y-carrying sperm and a
mature ovum results in a baby boy (XY). Important: Only fathers,
therefore, determine the sex of their children.
II. IMPLANTATION
A. Implementation after fertilization, the fertilization ovum or zygote stays
in the Fallopian tube for 3 days, during which time rapid cell division
(mitosis) is taking place. The developing cells are now called
blastomere and when there are already about 16 blastomeres, it is now
termed a morula. In this morula for, it will start to ravel (by ciliary
action and peristaltic contractions of the Fallopian tube) to the uterus
where it will stay for another 3-4 days. When there is already a cavity
formed in the morula, it is now called a blastocyst. Fingerlike
projections, called trophoblasts (Table 4), form around the blastocyst
and these trophoblasts are the ones which will implant high on the
anterior or posterior surface of the uterus. Thus, implantation, also
called nidation, takes place about a week after fertilization.
B. General Considerations
1. Once implantation has taken place, the uterine endothelium is now
termed decidua.
2. Occasionally, a small amount of vaginal spotting appears with
implantation because capillaries are ruptured by the implanting
trophoblasts = implantation bleeding. Implication: this should not
be mistaken for the Last Menstrual Period (LMP)
2.6 Protective barrier – inhibits the passage of same bacteria and large
molecules
G. Seventh Lunar Month – alveoli begin to form (28th weeks of gestation is said
to be the lower limit of prematurity because if baby is delivered at this time,
will cry and breathe but usually dies)
1.4 Because of poor circulation in the blood vessels of the genitalia due to
the pressure of the gravid uterus, varicosities of the vulva and rectum
can occur. Management: side-lying position with hips elevated on
pillow and modified knee-chest position.
1.5 There is increased level of circulating fibrogen, that is why pregnant
women are normally safeguarded against undue bleeding. However,
this also predisposes them to formation of blood clots (thrombi). The
implication is that pregnant women should not be massaged since
blood clots can be released and cause thromboembolism.
2. Gastrointestinal changes
2.1 Morning sickness – nausea and vomiting during the first trimester is
due to increased human chorionic gonadotropin (HCG). It may also
be due to increased acidity or even to emotional factors.
Management: Eat dry toast or crackers 30 minutes before arising in
the morning (or dry, high carbohydrate, low fat and low spices in the
diet).
2.2 Hyperemesis gravidarum = excessive nausea and vomiting which
persists beyond 3 months; results in dehydration, starvation and
acidosis. Management: D10NSS 300 ml in 24 hours is the priority
treatment; complete bed rest is also important.
2.3 Constipation and flatulence are due to displacement of the stomach
and intestines, thus slowing peristalsis and gastric emptying time.
May also be due to increased progesterone during pregnancy.
Management:
2.3.1 Increase fluids and roughage in the diet
2.3.2 Establish regular elimination time
2.3.3 Increse exercise
2.3.4 Avoid enemas
2.3.5 Avoid harsh laxatives like Dulcolax; stool softeners,
e.g. Colace, are better
2.3.6 Mineral oil should not be taken because it interferes
with absorption of fat-soluble vitamins.
4. Urinary changes
4.1 Urinary frequency, the only sign in pregnancy seen during the first
trimester disappears during the second and reappears during the
third trimester. Early in pregnancy is due to increased blood supply to
the kidneys and to the uterus rising out of the pelvic cavity; in the last
trimester is due to pressure of enlarged uterus on the bladder,
especially with lightning (descent of the fetus into the pelvic brim).
4.2 Decreased renal threshold for sugar due to increased production
of glucocorticoids which cause lactose and dextrose to spill into
the urine; also an effect of the increased progesterone.
(implication: it would be difficult to diagnose diabetes in
pregnancy based on the urine sample alone because a pregnant
women have sugar in their urine.)
5. Muscoloskeletal changes
5.1 Because of the pregnant woman’s attempt to change her center of
gravity, she makes ambulation easier by standing more straight
and taller, resulting in a lordotic position (“pride of pregnancy”)
5.2 Due to increased production of the hormone relaxin, pelvic bones
become more supple and movable, increasing the incidence of
accidental falls due to the wobbly gait. Implication: Advise use of
low-heeled shoes after the first trimester
5.3 Leg cramps
5.3.1 Causes
Increased pressure of gravid uterus on lower
extremities
Fatigue
Chills
Muscle tenseness
Low calcium, high phosphorus intake
5.3.2 Management
Frequent rest periods with feet elevated
Wear warm, more confortable clothing
Increase calcium intake (calcium tablets and diet)
Do not massage – blood clots can cause embolism.
Most effective treatment: Press knee of the affected leg
and dorsiflex the foot.
8. Weight (Table 5)
8.1 During the first trimester, weight gain of 1.5-3 lbs is normal
8.2 On 2nd and 3rd trimesters, weight gain of 10-11 lbs. per trimester is
recommended.
8.3 Total allowable weight gain during entire period of
pregnancy, therefore, is 20-25 pounds (10-12 kgs).
8.4 Pattern of weight gain is more important than the amount of weight
gained.
Fetus 7lbs.
Placenta 1 lb.
Amniotic fluid 1 ½ lbs.
Increased weight of uterus 2 lbs.
Increased weight of the breasts 1/1 – 3 lbs.
Weight of additional fluid 2 lbs.
Fat and fluid accumulation 4-6 lbs.
Characteristics of pregnancy
Total 20-25 lbs.
9. Emotional responses
9.1 First trimester. The fetus is an unidentified concept with great future
implications but without tangible evidence of reality. Some degree of
rejection, disbelief, even depression. (Implication: when giving health
teachings, emphasize the bodily changes in pregnancy).
9.2 Second trimester: fetus is perceived as a separate entity. Fantasizes
appearance of the baby.
9.3 Third trimester: has personal identification with a real baby about to
be born and realistic plans for future childcare responsibilities. Best
time to talk about layette and infant feeding method. Fear of death,
though is prominent (To allay fears, let pregnant woman listen to the
fetal heart sounds.)
2.2 The pH of the vagina changes from normally acidic (because of the
presence of Dederlein bacillie) to alkaline (because of increased
estrogen). Alkaline vaginal environment is supposed to protect
against bacterial infection; however, there are two microorganisms
which thrive in an alkaline environment.
2.2.1 Trichomonas, a protozoa or flagellate. The condition is
called trichomonas vaginalis or trichomonas vaginitis
or trichomoniasis.
Signs and symptoms of Trichomoniasis
Frothy, cream-colored, irritatingly itchy, foul-
smelling discharges
Vulvar edema and hyperemia due to irritation from
the discharges
Management
Flagyl for 10 days p.o. or vaginal suppositories of
trichomonicidal compounds. (e.g., Tricofuron,
Vagisec or Devegan).
o Is carcinogenic during the first trimester
o Treat male partner also with Flagyl.
o Avoid alcoholic drinks when taking Flagyl – can
cause Antabuse – like reactions: vomiting, flushed
face and abdominal cramps.
o Dark brown urine a minor side effect – no need to
discontinue the drug.
Acidic vaginal douche (1 tbsp. white vinegar in 1 quart
of water or 15 ml. white vinegar in 1000 ml. of water)
to counteract alkaline – preferred environment of the
protozoa.
Avoid intercourse to prevent reinfection
3. Abdominal Wall
3.1 Striae gravidarum – increase uterine size results in rupture and
atrophy of connective tissue layers, seen as pink or reddish streaks
(gently rubbing oil on the skin helps prevent diastasis)
3.2 Umbilicus pushed out
4. Skin
4.1 Linea nigra – brown line running from umbilicus to symphais pubis
4.2 Melasma or chloasma – extra pigmentation on cheeks and across the
nose due to increased production of melanocytes by the pituitary
gland
4.3 Sweat glands unduly activated
6. Ovaries – no activity whatsoever since ovulation does not take place during
pregnancy. Progesterone and estrogen are being produced by the placenta.
2. Assessment
2.1Physical examination – review of systems is indicated, including
inspection of the teeth because they are common foci of
infection.
2.2 Pelvic examination (Cardinal rule: Empty the bladder first)
1.2.1 Internal exam (IE) to determine Hegar’s, Chadwick’s, and
Goodell’s
2.2.2 Ballotement – fetus will bounce when lower uterine
segment is tapped sharply (on 5th month of pregnancy)
3.2.3 Papanicolau (Pap smear) – cytological examination to
diagnose cervical carcinoma.
Classification of findings
Class 1 – absence of a typical or abnormal cells
(normal)
Class 2 – atypical/abnormal cytology but no evidence
of malignancy
Class 3 – cytology suggestive of malignancy
Class 4 – cytology strongly suggestive of malignancy
Class 5 – conclusive for malignancy
Clinical stages that reflect localization or spread of
malignant cervical changes.
Stage 1 – CA confined to the cervix
Stage 2 – CA extends beyond the cervix into the
vagina, but not into the pelvic wall or lower 1/3 of the
vagina
Stage 3 – Metastasis to the pelvic wall
Stage 4 – Metastasis beyond pelvic wall into the
bladder and rectum
2.2.4 Pelvic measurements are preferably done after the 6th lunar
month. X-ray pelvimetry (several flat plate X-ray pictures of
the pelvis taken from different angles) is the most effective
method of diagnosing cephalopelvic disproportion (CPD).
But since X-rays are teratogenic, the procedure can be done
only 2 weeks before EDC.
2.2.5 Leopold’s maneuvers
Purposes
To determine presentation, position, and gratitude
Estimate fetal size
Locate fetal parts
Preparatory steps
Palpate with warm hands; cold hands cause
abdominal muscles to contract
Use palms, not fingertips
Position patient on supine with knees flexed slightly
(dorsal recumbent position) so as to relax
abdominal muscles.
Apply gentle but firm motions
Procedure
First manever: Facing head part of pregnant woman,
palpate for fetal part found in the fundus to
determine presentation (a hard, smooth, ballotable
mass at the fundus means the fetus is in breech
presentation
Second maneuver: Palpate sides of the uterus to
determine the location of fetal back (best place to
hear fetal heart tones) and small fetal parts
Third maneuver: Grasp lower portion off abdomen
just above the symphysis pubis to find out degree of
engagement.
Fourth maneuver: Facing the feet part of the patient,
press fingers downward on both sides of the uterus
above the inguinal ligaments to determine attitude
(degree of flexion of fetal head)
3. Important Estimates
3.1 Age of Gestation (AOG)
3.1.1 Nagele’s Rule – calculation of expected date of confinement
(EDC). Count back three months from the first day of the last
menstrual period (LMP) then add 7 days. Substitute number
for month for easy computation. E.g., LMP is September 6
September is the 9th month of the year – 3 = 6 (June)
Add 7 days to 6 = 13
EDC – June 13
3.1.2 McDonald’s Method – determine age of gestation by
measuring from the fundus to the symphysis pubis (in cm.)
then divide by 4 = AOG in months. E.G., fundic height of 16
cm. divided by 4 = 4 months AOG = 16 weeks AOG.
3.1.3 Bartholomew’s Rule – estimate AOG by the relative position
of the uterus in the abdominal cavity (Figure 4).
By the 3rd lunar month, the fundus is palpable slightly
above the symphysis pubis
On the 5th lunar month, the fundus is at the level of the
umbilicus
On the 9th lunar month, the fundus is below the xiphoid
process
Bartholomew’s Rule
Active Non-Pregnant
Food Pregnant Women
Women
Meat 2 servings of meat, fowl or 2-3 servings of meat,
fish/day; 3-5 eggs/week fowl or fish/day; 1
egg/day
Vegetables specially dark 1 serving/day (at least 1 serving/day
green and deep yellow 3/week)
Fruits: Citrus and others 2 or more servings/day 2-3 servings/day
Breads 1 serving/day 1 servings/day
Milk 4 or more servings/day 4 servings/day
Additional fluid 1 pint (6-8 oz. glasses /day) 1 quart (2-6 glasses/day)
4.6 Employment – as long as the job does not entail handling toxic
substances, or lifting heavy objects, or excessive physical or emotional
strain, there is no contraindication to working. Advise pregnant
women to walk about every few hours of her work day long periods of
standing or sitting to promote circulation.
4.7 Traveling – no travel restrictions but postpone a trip during the last
trimester. On long rides, 15-20 minute rest periods every 2-3 hours to
walk about or empty the bladder is advisable.
4.8 Exercises
4.8.1 Chief aim: To strengthen the muscles used in labor and
delivery
4.8.2 Should be done in moderation
4.8.3 Should be individualized: according to age, physical
condition, customary amount of exercises (swimming or
tennis not contraindicated unless done for the first time) and
the stage of pregnancy)
4.8.4 Recommended exercises
Squatting (Figure 5) and Tailor Sitting (Figure 6) – to
stretch and strengthen perineal muscles; increase
circulation in the perineum; make pelvic joints more
pliable. When standing from squatting position, raise
buttocks first before raising the head to prevent postural
hypotension.
Pelvic rock – maintains good posture; relieved pressure
abdominal pressure and low backache; strengthens
abdominal muscles following delivery
Modified knee-chest position - relieves pelvic pressure
and cramps in the thighs or buttocks; relieves discomfort
from hemorrhoids
Shoulder-circling – strengthens muscles of the chest
Walking – said to be the best exercises
Kegel – relieves congestion and discomfort in pelvic
region; tones up pelvic floor muscles
4.9 Prepared Childbirth/Childbirth Education – preparing the pregnant
couple for childbearing
4.9.1 Operates basically on the “Gate Control Theory” of pain: pain
is controlled in the spinal cord. To ease pain in one body
part, the “gate” to this pain should be “closed”.
4.9.2 Premises
Discomfort during labor can be minimized if the woman
comes into labor informed about what is happening and
prepared with breathing exercises to use during labor
Discomfort during labor can be minimized if the woman’s
abdomen is relaxed and the uterus is allowed to rise freely
against the abdominal wall during contractions.
4.10 Tetanus immunization – given 0.5 ml IM (deltoid region of the upper arm) to
all pregnant women anytime during pregnancy. It shall be given in two doses
at least 4 weeks apart, with the second dose at least 3 weeks before delivery.
Booster doses shall be given during succeeding pregnancies regardless of the
interval. Three booster doses will confer lifelong immunity.
4.11 Clinic appointments
4.11.1 First 7 lunar month – every month
4.11.2 On 8th and 9th lunar month – every other week or twice a month
4.11.3 On 10th lunar month – every week until labor pains set in
B. Cranial bones - the first 3 are not important part of the fetus because
it is the:
1. Sphenoid
2. Ethmoid
3. Temporal
4. Frontal
5. Occipital
6. parietal
C. Membrane space – suture lines are important because they allow the
bones to move and overlap, changing the shape of the fetal head in
order to fit through the birth canal, a process called molding.
1. Sagittal suture line – the membranous interspace which joins the
parietal bones
2. Coronal suture line – the membranous interspace which joins the
frontal bone and the parietal bones
3. Lambdoid suture line – the membranous interspace which joins
the occiput and the parietals.
Which one of these diameters is presented at the birth canal depends on the
degree of flexion (known as attitude) the fetal head assumes prior to delivery. In
full flexion (very good attitude when the chin is flexed on the chest), the smalles
suboccipitobregmatic diameter (A) is the one presented at the birth canal. If in
poor flexion, the widest occipitomental diameter (D) will be the one presented and
will give mother and the baby more problems.
6. Nursing Care
3.1 Hospital admission – provide privacy and reassurance from the very start
3.1.1 Personal data – name, age, address, civil status
3.1.2 Obstetrical data – determine EDC; obstetrical score (gravida, para,
TPAL); amount and character of show; and whether or not
membranes have ruptured.
3.2 General physical examination, internal exam and Leopold’s maneuvers
are done to determine:
3.2.1 Effacement and dilatation
3.2.2 Station – relationship of the fetal presenting part to the level of the
ischial spine (Figure 14)
Station 0 – at the level of the ischial spines; synonymous to
engagement
Station -1 – presenting part above the level of the ischial spines
Station +1 – presenting part below the level of the ischial spines
Station +3 or +4 – synonymous to crowning (encircling of the
largest diameter of the fetal head by the vulvar ring)
I. VERTICAL
A. Cephalic – head is the presenting part
1. Vertex – head sharply flexed, making the parietal bones the presenting parts
2. If in poor flexion
2.1 Face
2.2 Brow
2.3 Chin
C. Footling
1. Single – one leg unflexed and extended; one foot presenting
2. Double – legs unflexed and extended; feet are presenting
II. HORIZONTAL = Transverse lie = Shoulder presentation
In vertex presentation, FHS are usually located in either the left
or right lower quadrant (LLQ or RLQ); in breech presentation,
at or above the level of the umbilicus, either left or right upper
quadrant (LUQ or RUQ)
Hazards of breech delivery
Cord compression
Abruptio placenta
Erb – Duchenne paralysis
Horizontal lie is very rare (1%) and maybe due to a relazed
abdominal wall because of multiparity, pelvic contraction or
placenta previa
A B C D
3.4 Emotional support is provided for the woman in labor by keeping her
constantly informed of the progress labor
3.5
3.5.3 Solid or liquid foods are to be avoided because
Digestion is delayed during labor
A full stomach interferes with proper bearing down
May vomit and cause aspiration
3.5.4 Enema – not a routine procedure
Purposes
A full bowel hinders the progress of labor – effectiveness of
enema in labor can be determined by evaluating change in
uterine tone and the amount of show
Expulsion of feces during second stage of labor predisposes
mother and baby to infection
Full bowel predisposes to postpartum discomfort
Procedure of enema administration
Enema solution may either be soap suds or Fleet enema
(contraindicated in patients with toxemia because of its
sodium content)
Optimum temperature of the solution – 105°F to 115°F (40.5 °C
– 46.1°C)
Patient on side – lying position
When there is resistance while inserting rectal catheter,
withdraw the tube slightly while letting a small amount of
solution enter
Clamp rectal tube during a contraction
Important nursing action: Check FHR after enema
administration to determine fetal distress
Contraindications to enema in labor
Vaginal Bleeding
Premature labor
Abnormal fetal presentation or position
Ruptured membranes
Crowning
3.5.5 Encourage the mother to void every 2 – 3 hours by offering the
bedpan because
A full bladder retards fetal descent
Urinary stasis can lead to urinary tract infection
A full bladder can be traumatized during delivery
3.5.6 Perineal prep – done aseptically. Use “No. 7” method, always from
front to back
3.5.7 Perineal shave – not a routine procedure; maybe done to provide a
clean area for delivery. Muscles at the symphysis pubis should be
kept taut and razor moved along the direction of hair growth
3.5.8 Encourage Sim’s position because it:
Favors anterior rotation of the fetal head
Promotes relaxation between contractions
Prevents continual pressure of the gravid uterus on the inferior
vena cava (the blood vessel which brings unoxygenated blood
back to the heart); pressure results in Supine Hypotensive
Syndrome, also called Vena Cava Syndrome (Figure 16).
Hypotension is due to the reduced venous return resulting in
decreased cardiac output and therefore, a fall in arterial BP.
3.5.9 Woman in labor should not be allowed to push or bear down
unnecessarily during contractions of the first stage because
It leads to unnecessary exhaustion
Repeated strong pounding of the fetus against the pelvic floor
will lead to ce4rvical edema, thus interfering with dilatation and
prolonging length of labor.
3.5.10 Abdominal breathing – advised for contractions during the first
stage in order to reduce tension and prevent hyperventilation
B Transition Period – when the mood of the woman suddenly changes and the
nature of contractions intensify
1. Characteristics
1.1 If membranes are still intact, this period is marked by a sudden gush of
amniotic fluid as fetus is pushed into the birth canal. If spontaneous
rupture does not occur, amniotomy (snipping of BOW with a sterile
pointed instrument, e.g., Kelly or Allis forceps or amniohook to allow
amniotic fluid to drain) is done to prevent fetus from aspirating the
amniotic fluid as it makes its different fetal position changes.
Amniotomy, however, can not be done if station is still “minus”, as this
can lead to cord compression
1.2 Show becomes more prominent.
1.3 There is an uncontrollable urge to push with contractions, a sign of
impending second stage of labor. Profuse perspiration and distention of
neck veins are seen.
1.4 Nausea and vomiting is a reflex reaction due to decreased gastric
motility and absorption.
1.5 In primis, baby is delivered with 20 contractions (40 minutes); in
multis, after 10 contractions (20 minutes).
2. Nursing actions are primarily comfort measures
2.1 Sacral pressure (applying pressure with the heel of the hand on the
sacrum) relieves discomfort from contractions
2.2 Proper bearing down techniques: push with contractions
2.3 Controlled chest (costal) breathing during contractions
2.4 Emotional support
D Third Stage (Placental Stage) – begins with the delivery of the baby and ends
with delivery of placenta.
1. Signs of placental separation
1.1 Uterus becoming round and firm again, rising high to the level of the
umbilicus (Calkin’s sign) – the earliest sign of placental separation
1.2 Sudden gush of blood from the vagina
1.3 Lengthening of the cord
2. Types of placental delivery
2.1 Schultz – if placenta separates first at its center and last at its edges, it
tends to fold on itself like an umbrella and presents the fetal surface
which is shiny (“Shiny” for Schultz); 80% of placentas separate in this
manner.
2.2 Duncan – if placenta separates first at its edges, it slides along the
uterine surface and presents with the maternal surface which is raw, red,
beefy, and irregular and “dirty” (“Dirty” for Duncan). Only about 20% of
placentas separate this way.
3. Nursing Care
3.1 Do not hurry the expulsion of the placenta by forcefully pulling out the
cord or doing vigorous fundal push as this can cause uterine inversion.
Just watch for the signs of placental separation.
3.2 Tract the cord slowly, winding it around the clamp until the placenta
spontaneously comes out, slowly rotating it so that no membranes are
left inside the uterus, a method called Brandt – Andrews maneuver.
3.3 Take note of the time of placental delivery. It should be delivered
within 20 minutes after the delivery of the baby. Otherwise, refer
immediately to the doctor as this can cause severe bleeding in the
mother.
3.4 Inspect for completeness of cotyledons; any placental fragment retained
can also cause severe bleeding and possible death.
3.5 Palpate the uterus to determine degree of contraction. If relaxed boggy
or non - contracted, first nursing action is to massage gently and
properly. An ice cap over the abdomen will also help contract the uterus
since cold causes vasoconstriction.
3.6 Inject oxytocin (Methergin = 0.2 mg./ml. or Syntocinon = 10U/ml) IM
to maintain uterine contractions, thus prevent hemorrhage. Note:
oxytocins are not given before placental delivery.
3.7 Inspect the perineum for lacerations. Any time the uterus is firm
following placental delivery, yet bright red vaginal bleeding is gushing
forth from the vaginal opening, suspect lacerations (tend to heal more
slowly because of ragged edges)
3.7.1 Categories of lacerations
First degree – involves the vaginal mucous membranes and
perineal skin
Second degree – involves not only the muscles, vaginal mucous
membranes and skin, but also the muscles.
Third degree – involves not only the vaginal mucous
membranes and skin, but also the external sphincter of the
rectum
Fourth degree – involves not only the external sphincter of the
rectum, the muscles, vaginal mucous membranes and skin, but
also the m mucous membranes of the rectum.
3.7.2 Assist the doctor in doing episiorrhaphy 9repair of episiotomy or
lacerations). In vaginal episiorrhaphy, packing is done to maintain
pressure on the suture line, thus prevent further bleeding. Note:
Vaginal packs have to be removed after 24 – 48 hours
E Fourth Stage – first 1 – 2 hours after delivery which is said to be the most
critical stage for the mother because of unstable vital signs.
1. Assessment
1.1 Fundus – should be checked every 15 minutes for 1 hour then every
30 minutes for the next 4 hours. Fundus should be firm, in the
midline, and during the first 12 hours postpartum, is a little above
the umbilicus. First nursing action for a non- contracted uterus:
massage.
1.2 Lochia – shuld be moderate in amount. Immediately after delivery, a
perineal pad can be completely saturated after 30 minutes. If
saturated in 15 minutes or earlier, may mean hemorrhage.
1.3 Bladder – a full bladder is evidenced by a fundus which is to the
right of the midline and dark – red bleeding with some clots. Will
prevent adequate uterine contraction.
1.4 Perineum – is normally tender, discolored and edematous. It should
be clean, with intact sutures.
1.5 Blood pressure and pulse rate may be slightly increased from
excitement and effort of delivery, but normalize within one hour.
2. Lactation – suppressing agents – estrogen – androgen preparations given
within the first hours postpartum to prevent breast milk production in
mothers who will not (or cannot) breastfeed. E.g., diethylstilbestrol, TACE,
Parlodel and deladumone. These drugs tend to increase uterine bleeding
and retard menstrual return
3. Rooming – in concept – mother and baby are together while in the
hospital. The concept of a family, therefore, is felt from the very beginning
because parents have the baby with them, thus providing opportunities for
developing a positive relationship between parents and newborn (maternal
– infant bonding). Eye – to –eye contact is immediately established,
releasing the maternal caretaking responses.
PUERPERUM
I. DEFINITION OF TERMS
A. Puerperium/Postpartum – refers to the six – week period after delivery of
the baby
B. Involution - return of the reproductive organs to their prepregnant state
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8 21
RISK CONDITIONS
I. INFECTIONS
A. Syphilis
1. Cause: Treponema pallidum – a spirochete which enters the body
during coitus or through cuts and breaks in the skin or mucous
membrane
2. Treatment: 2.4-4.8 million units of Penicillin (if allergic, 30-40 gms.
erythrocin) will usually prevent congenital syphilis in the newborn
because penicillin readily crosses the placenta. If untreated, syphilis
can cause midtrimester abortion, CNS lesions in the newborn or even
death.
3. The newborn with congenital syphilis
3.1 Signs and symptoms
3.1.1 Jaundice at 2 weeks of life – first sign of the disease
3.1.2 Anemia and hepatosplenomegaly
3.1.3 “Snuffles” (persistent rhinorrhea); coppery rashes
on palms and soles; mucous patches; condylomas;
pseudoparalysis due to bone inflammation
3.1.4 If untreated, can progress on to deformed bones,
teeth, nose, joints and CNS syphilis
3.2 Management: Penicillin IM for 10 days or one long-acting
Penicillin (Penadur LA)
B. Rubella/German Measles
1. Incidence
1.1 Mother – the earlier the mother contracted the disease, the
greater the likelihood that the baby will be affected. The
rubella virus slows down division of infected cells during
organogenesis, thus causing congenital defects
1.2 Newborn – can carry and transmit the virus for as long as 12-24
months after birth
2. Signs and symptoms of Congenital Rubella Syndrome
2.1 Low birth weight; jaundice; petechiae; anemia;
thrombocytopenia; hepatosplenomegaly
2.2 Classic seequelae
2.2.1 Eyes: chorioretinitis, cataract, glaucoma
2.2.2 Heart: Patent Ductus Arteriousus, stenosis,
coarctations
2.2.3 Ear: Nerve deafness
2.2.4 Dental and facial clefts
C. Postpartum Infection
1. Sources
1.1 Endogenous (primary) sources – bacteria in the normal flora
become virulent when tissues are traumatized and general
resistance is lowered.
1.2 Exogenous sources – pathogens introduced from external
sources. (Most common is anaerobic streptococci). Common
exogenous sources:
1.2.1 Hospital personnel
1.2.2 Excessive obstetric manipulations
1.2.3 Breaks in aseptic techniques – faulty handwashing,
unsterile equipments and supplies
1.2.4 Coitus in late pregnancy
1.2.5 Premature rupture of the membranes
2. General symptoms: malaise anorexia, fever, chills and headache
3. General management
3.1 Complete bed rest (CBR)
3.2 Proper nutrition
3.3 Increased fluid intake
3.4 Analgesics
3.5 Antipyretics and antibiotics, as ordered
4. Types of infection
4.1 Infection of the perineum
4.1.1 Specific symptoms
Pain, heat and feeling of pressure in the
perineum
Inflammation of the suture line, with 1 or 2
stitches sloughed off
With or without elevated temperature
4.1.2 Specific management
Doctor removes sutures to drain area and
resutures
Hot sitz bath or warm compress
4.2 Endometritis
4.2.1 Specific symptoms
Abdominal tenderness
Uterus not contracted and painful to touch
Dark brown, foul-smelling lochia
4.2.2 Specific management
Oxytocin administration
Fowler’s position to drain out lochia and prevent
pooling of infected discharge
4.3 Thrombophlebitis – infection of the lining of a blood vessel
with formation of clots; usually an extension of endometritis
4.3.1 Specific symptoms
Pain, stiffness and redness in the affected part of
the leg
Leg begins to swell below the lesion because
venous circulation has been blocked
Skin is stretched to a point of shiny whiteness,
called milk leg or phlegmasia alba dolens
Positive Homan’s sign – pain in the calf when
the foot is dorsiflexed
4.3.2 Specific management
Bed rest with affected leg elevated
Anticoagulants, e.g., Dicumarol or Heparin, to
prevent further clot formation or extension of a
thrombus
o Analgesics are given but never Aspirin
because it inhibits prothrombin
formation therefore causes hemorrhage
4.4 Mastitis – inflammation of breast tissues
4.4.1 Pathophysiology – local inflammatory response to
bacterial invasion; suppuration may occur; organism
can be recovered from breast milk.
4.4.2 Etiology – most common: Staphylococcus aureus
4.4.3 Assessment
Signs of infection (may occur several weeks
postpartum).
Fever
Chills
Tachycardia
Malaise
Abdominal pain
Breast
Reddened areas
Localized/generalized swelling
Heat, tenderness, palpable mass.
4.4.4 Nursing care – goal: prevent infection. Health
teaching in early postpartum
Handwashing
Breast care
Wash with warm water only (no soap)
Let breast milk dry on nipples to prevent
drying of tissue.
Clean bra (with no plastic pads or liners)
to support breasts, reduce friction,
minimize exposure to microorganisms.
Good breastfeeding techniques
II. BLEEDING/HEMORRHAGE
A. Bleeding in pregnancy (Table 13)
I. First Trimester Bleeding
A. Abortion
1. Spontaneous
1.1 Threatened
1.2 Imminent
1.2.1 Complete
1.2.2 Incomplete
2. Induced
3. Missed
B. Ectopic pregnancy
1. Tubal – most common
2. Cervical
3. Ovarian
II. Second Trimester Bleeding
A. Hydatidiform Mole
B. Incompetent Cervical Os
III. Third Trimester Bleeding
A. Placenta Previa
B. Abruptio Placenta
release
Albumin& globulin cross Water retention Epigastric pain thromboplastin
into the urine like substances
PROTEINURIA
EDEMA OLIGURIA
Premature placental
deterioration
Fluid diffuses from
circulatory system to
Fetal Abruptio
extracellular spaces nutrient placenta
Generalized water
retention
LUNGS BRAIN
Fetal Distress
Premature Labor
and Delivery
CHF Cerebral irritability
1.1.2 Generalized vasoconstriction and associated
microangiopathy disease of capillaries
1.1.3 Abnormal retention of sodium and water by body
tissues
1.2 Medical complications
1.2.1 Cerebrovascular hemorrhage
1.2.2 Acute pulmonary edema
1.2.3 Acute renal failure
1.3 Types
1.3.1 Mild preeclampsia – signs and symptoms
Sudden, excessive weight gain of 1-5 lbs. per
week (earliest sign of preeclampsia) due to
edema which is persistent and found in the
upper half of the body (e.g. inability to wear
the wedding ring)
Systolic BP of 140, or an increase of 30mm.
Hg. or more and a diastolic of 90, or a rise
of 15 mm. Hg. or more, taken twice 6 hours
apart.
Proteinuria of 0.5 gms/liter or more
1.3.2 Severe preeclampsia – signs and symptoms
BP of 160/110 mm Hg.
Proteinuria of 5 gm/liter or more in 24 hours
Oliguria of 400 ml. or less in 24 hours
(normal urine output/day = 1500 ml).
Cerebral or visual disturbances
Pulmonary edema and cyanosis
Epigastric pain (considered an “aura” to the
development of convulsions)
2. Eclampsia – the main difference between preeclampsia and Eclampsia is
the presence of convulsion in eclampsia. Signs and symptoms as in
preeclampsia plus:
2.1 increased BUN
2.2 increased uric acid
2.3 decreased CO2 combining power
F. Management
1. Complete bed rest – sodium tends to be excreted at a more rapid rate if
the patient is at rest. Energy conservation is important in decreasing
metabolic rate to minimize demands for oxygen. Lowered oxygen
tension in toxemia is the result of vasoconstriction and decreased blood
flow that diminishes the amount of nutrients and oxygen in cells. In
any condition wherein there is a possibility of convulsions, bed rest
should be in a darkened, non-stimulating environment with minimal
handling.
2. Diet
2.1 For mild preeclampsia – high protein, high carbohydrate,
moderate salt restriction (no added table salt, including
“bagoong”, “patis”, “tuyo”, canned goods, bottled drinks,
preserved foods and cold cuts)
2.2 For severe preeclampsia – high protein, high calorie and salt-
poor (3 gms of salt per day)
3. Medications
3.1 Diuretics – e.g., chlorthiazide/Diuril. Hourly urine
output should be at least 20-30 ml. (normally 50-60 ml.
per hour)
3.1.1 Pharmacologic effect: decreased reabsorption
of sodium and chloride at the proximal tubules,
thereby increasing renal excretion of sodium,
chloride and water, including potassium.
3.1.2 Side effects: fatigue and muscle weakness due
to fluid and electrolyte imbalance
3.1.3 Nursing care: closely monitor intake and
output
3.2 Digitalis – if with heart failure.
3.2.1 Pharmacologic action: Increase the force of
contraction of heart, thereby decreasing heart
rate.
3.2.2 Important: Should not be given, therefore, if
heart rate is below 60/minute.
3.2.3 Implication: take the heart rate before giving
the drug.
3.3 Potassium supplements – patients receiving diuretics are
prone to hypokalemia; if digitalis is given at the same
time, hypokalemia increases the sensitivity of the heart to
the effects of digitalis. Potassium supplements (e.g.,
banana) must be given tot prevent cardiac arrhythmias.
3.4 Barbiturates – sedation by means of CNS depression
3.5 Analgesics; antihypertensives; antibiotics;
anticonvulsants; sedatives
3.6 Magnesium sulfate – the drug of choice
3.6.1 Actions
CNS depressant – lessen the possibility of
convulsions
Vasodilator – decreases the BP
Cathartic causes a shift of fluid from the
extracellular spaces into the intestines
from where the fluid can be excreted.
3.6.2 Dosage: 10 gms. initially, either by slow IV push
over 5-10 minutes, or deep IM, 5 gms/buttock,
then IV drip of 1 gm. per hour (1 gm/100 ml.
D10W) IF:
Deep tendon reflexes are present
Respiratory rate is at least 12 per minute
Urine output is at least 100 ml. in 6 hours
3.6.3 Antidote for magnesium sulfate toxicity:
Calcium gluconate, 10% IV, to maintain cardiac
and vascular tone.
3.6.4 Earliest sign of magnetism sulfate toxicity:
disappearance of the knee jerk/patellar reflex.
4. Method of delivery – preferably vaginal, but if not possible, CS
will have to be done.
G. Prognosis: the danger of convulsions is present until 48 hours
postpartum.
V. HEART DISEASE
A. Classification
1. Class I – no limitation physical activity
2. Class II – slight limitation of physical activity; ordinary activity causes
fatigue; palpitation, dyspnea or angina
3. Class III – moderate to marked limitation of physical activity; less than
ordinary activity causes fatigue, etc.
4. Class IV – unable to carry on any activity without experiencing
discomfort
B. Prognosis
1. Classes I and II – normal pregnancy and delivery
2. Classes III and IV – poor candidates
C. Signs and symptoms
1. Because of increased total cardiac volume during pregnancy, heart
murmurs are observed
2. Cardiac output may become so decreased that vital organs are not
perfused adequately; oxygen and nutritional requirements, therefore,
are not met.
3. Since the left side of the heart is not able to empty the pulmonary
vessels adequately, the latter become engorged, causing pulmonary
edema and hypertension. Moist cough in gravidocardiacs, therefore, is
a danger sign.
4. Liver and other organs become congested because blood returning to
the heart may not be handled adequately, causing the venous pressure
to rise. Fluid then escapes through the walls of engorged capillaries
and cause edema or ascites.
5. Congestive heart failure is a high probability also because of the
increased cardiac pain on exertion, and cyanosis of nailbeds are
obvious.
D. Management – consider the functional capacity of the heart
1. Bed rest – especially after the 30th week of gestation to ensure that
pregnancy is carried to term or at least 36 weeks gestation
2. Diet – should gain enough, but not too much as it would add to the
workload of the heart
3. Medications
3.1 Digitalis
3.2 Iron preparations, e.g., Fer-in-sol or Feosol – anemia should be
prevented because the body compensates by increasing cardiac
output, thus further increasing cardiac workload.
4. Classes III and IV are not placed in lithotomy position during delivery
to avoid increasing venous return. The semi-sitting position is
preferred to facilitate easy respirations.
5. Anesthetic of choice is caudal anesthesia for effortless, pushless and
painless delivery. Remember: Gravidocardiacs are not allowed to push
with contractions (to prevent Valsalva maneuver which increases
venous return to an already weak, damaged heart). Low forceps,
therefore, is the best method of delivery.
6. ergotrate and other oxytocics, scopolamine, diethylstilbestrol and oral
contraceptives are contraindicated because they cause fluid retention
and promote thromboembolization.
7. Most critical period – the period immediately following delivery
because the 30% - 500
VI. MULTIPLE PREGNANCY (Twin Pregnancy)
A. Classification
1. Monozygotic/Identical – twins begin with a single ovum and sperm,
but in the process of fusion or in one of the first cell divisions, the
zygote divides into two identical but separate individuals.
1.1 Characteristics
1.1.1 Always of the same sex
1.1.2 With 2 amnions, 1 chorion, 2 umbilical cords and 2
placentas fused as one.
1.2 Incidence – a chance occurrence
1.2.1 More frequent among non-whites
1.2.2 More frequent among young primis and old multis
2. Dizygotic/Fraternal – two separate ova are fertilized by 2 separate
sperms. They are actually sibling growing at the same time in utero.
2.1 Characteristics
2.1.1 May or may not be of the same sex
2.1.2 With 2 amnions, 2 chorions, 2 placentas and 2
umbilical cords
2.2 Incidence – familial maternal pattern of inheritence
B. Suspect multiple pregnancy if:
1. faster rate of increase in uterine size
2. on quickening, there are several flurries of action in different
abdominal positions
3. on auscultation, 2 sets of fetal heart tones are heard
4. there is marked weight gain, not due to toxemia or obesity
C. complications
1. Toxemia 4. Abruptio placenta
2. Polyhydramnios 5. Prematurity
3. Anemia 6. Postpartum hemorrhage