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Woman’s Health

MATERNAL and
NEWBORN
NURSING
Jane Lou Estrabela Gargaritano,
 The Contents
Anatomy & Physiology
Female Reproductive
System
Female Reproductive Cycle
Endometrial Cycle
Ovarian Cycle
Fertilization
Fetal Development
Confirmation of Pregnancy
Physiologic Changes of
Anatomy & Physiology
Pregnancy
Antepartum Assessment &
Care
Assessment of Fetal Maturity
and Well Being
Health Education
Discomforts of Pregnancy
Danger Signs of Pregnancy
Labor and Delivery
Preparation for Childbirth
Anatomy & Physiology
Pregnancy (cont…)
Signs of Impending Labor
True Labor vs. False Labor
Cardinal Movements
Stages of Labor
Puerperium
Psychosocial Adaptation
Postpartum Blues
Postpartal Depression
Anatomy & Physiology
Complications of Pregnancy

 Bleeding Disorders of the 1st


Trimester
 Bleeding Disorders of the 2nd
Trimester
 Bleeding Disorders of the 3rd
Trimester
 Premature Rupture of Membranes
(PROM)
 Premature Labor and Birth
 Multiple Gestation
Anatomy & Physiology
Complications of Labor and
Delivery
Obstetric Interventions

Hypertensive Disorder of

Pregnancy
Other Complications of

Pregnancy
ANATOMY

&
PHYSIOLOGY
FEMALE
REPRODUCTIVE
SYSTEM
The External Genitalia
Collectively called VULVA ( pudenda )
Mons Pubis (Mons Veneris)
Labia Majora (Lar ger Lips)
Labia Minora (Labium Minus)
Clitoris
A small ( approx 1-2 cm ) rounded
organ of erectile tissue at the upper
end of labia minora
- plentiful arterial blood supply
nGlans - tip of the clitoral body
nPrepuce - hood like covering
nSmegma - epidermal secretion with

strong odor
Clitoris
FEMALE CIRCUMCISION

19
FEM ALE CIRCUMCISION
1 . CLITORIDECTOMY
2.
3 . EXCISION
4.
5 . INFIBULATION

20
Female Reproductive System

 Vestibule

 Almond-shape space
between the labia
minora, clitoris and
fourchette
Female Reproductive
System
contains structures:

 ☞ Urethral meatus -
 ☞ Vaginal introitus – G

SPOT
 ☞ Hymen


Carunculae myrtiformes

(hymenal caruncles)
 ☞ Skene’s glands – U
SPOT
 ☞ Bartholin’s glands
Female Reproductive System


FOURCHETTE – ridge of
tissue joining the two
labia

 PERINEUM
 Skin-colored muscular area
between the vaginal orifice
and the anus

fourchette

perineum
 INTERNAL
STRUCTURES
Female Reproductive System
 VAGINA

 Organ of copulation
 “birth canal”
 Fornix - “pouch of
Douglas”
- Deepest portion of the

vagina
- A SPOT


Vagina
For nix
ANNA SWAN
30
Lisa
Sparxxx

31
Female Reproductive
System


UTERUS
“The Womb”

UTERUS
HOLLOW, MUSCULAR, PEAR SHAPED ORGAN
POSTERIOR TO THE BLADDER
ANTERIOR TO THE RECTUM

34
UTERUS “THE WOMB”
HOUSES AND NOURISHES THE
FETUS UNTIL BIRTH

NORMAL POSITION:

ANTEVERTED – tipped forward


ANTEFLEXED – bent forward

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37
Nurse Nene is providing information to nursing
students about female reproductive system. While
discussing the uterus & its different layers, nurse
Nene understands that the muscle layer ideally suited
for the birth process is?

a.Endometrium
b.Perimetrium
c.Isthmus
d.Myometrium
Female Reproductive System
 Layers :
 1 . PERIMETRIUM / PARAMETRIUM
2 . MYOMETRIUM

- middle layer
- “living ligature”
Female Reproductive
System
ENDOMETRIUM
 - innermost
 - vascular
 - mucus-producing
layer
- Responds to

estrogen &
LAYERS
BASAL LAYER – nearest to
myometrium
Regenerates the
functional layer

FUNCTIONAL LAYER – sheds
during childbirth &
menstrual period 43

Female Reproductive
System
 Parts:

Cor pus
(body)


ISTHMUS
Female Reproductive
System


CERVIX
 - forms the main
opening
 of the uterus; about
2-3 cm
 • internal os
 • cervical os
 • external os
Female Reproductive System

 Supporting ligaments:


BROAD
 2 winglike structures that
extends from the lateral
margin to the uterus to
the pelvic walls

Female Reproductive
System


ROUND
 2 fibrous cords from
the uterine walls that
helps hold the uterus
in its forward position
Female Reproductive
System


POSTERIOR
(uter osacr al)

 2 cord-like folds of the


peritoneum from the lower
cervix to the sacrum
Female Reproductive System


Fallopian Tubes


“oviducts”
FALLOPIAN TUBES
8 – 14 CM IN LENGTH
PATHWAY FOR THE OVUM BETWEEN
THE OVARY AND THE UTERUS

55
Female Reproductive System
Parts:

a. INTERSTITIAL

Female Reproductive System
Isthmus
Ampulla


Infundibulum
Female Reproductive
System
 OVARIES
- the sex glands sized and
shaped like almonds
- Function is to produce,
mature, and discharge ova.
 Functions:
1. Ovulation
2. Secretion of hormones
 Estrogen
 Progesterone
OVARIES
Produces hormones that :

Maintain the SECONDARY SEX
CHARACTERISTICS
Prevent osteoporosis
Keep cholesterol levels reduced

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OVARIES
2 MILLION OVA – at birth

200 , 000 – 400 , 000 –
PUBERTY

400 ova – will be mature
enough

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1. This is considered as the site of episiotomy:
A.Vestibule
B.Fourchette
C.Labia Minora
D.Isthmus of the Fallopian Tube

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2. A student nurse was studying about the
different layers of the uterus. He asked you about
the part of the uterus that is most responsive to
changes in hormonal levels. You are correct if you
answer which of the following?
A.Parametrium
B.Endometrium
C.Myometrium
D.None of the above

68
3. In tubal ligation, the nurse must know that
the part of the fallopian tube that is tied ,
severed, or cut is:
A.Isthmus
B.Ampulla
C.Infundibulum
D.Fimbriae

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4. The widest portion of the fallopian tube is
the:
A.Isthmus
B.Ampulla
C.Infundibulum
D.Fimbriae

70
5. Skene's glands are secretory structures
usually found near the:
A.Urethral meatus
B.Vaginal introitus
C.Fourchette
D.Perineum

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Accessory Structures
PELVIS
PELVIS
Serves to both support and
protect the reproductive and
other pelvic organs.

74
Female Reproductive
System

PELVIS
 formed by
- 2 innominate bones
- each bone
- ( ilium,
 ischium,
 pubis )
 - sacrum
- coccyx
SACRUM – back portion of pelvis
- made up of 5 fused sacral
vertebrae
SACRAL PROMONTORY

COCCYX – composed of 4 – 5 fused


bones.

77
Female Reproductive
System
 Pelvic sections:

FALSE pelvis – lies above the
inlet
Female Reproductive System

TRUE pelvis
 pelvic inlet – entrance to
the true pelvis
 midpelvis – mid
portion of pelvis
- contains ischial
spine
pelvic outlet – exit of the true
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Female Reproductive System
 Measurements:

Diagonal
Conjugate
 – anterior sacral
promontory to the
INFERIOR margin of
symphysis pubis
Diagonal
Conjugate

12.5 - 13 cm
Female Reproductive System

Tr ue Conjugate
 - from anterior sacral
promontory to the
SUPERIOR margin of
symphysis pubis
 - 11 – 11.5cm
True
Conjugate

11 - 11.5 cm
Female Reproductive System


Biischial
diameter
 – distance between
ischial tuberosity
Biischial
diameter
BREAST
Female Reproductive System
parts:

1. Acini cells


2. Lactiferous duct
3. Lactiferous sinus
4. Nipples
5. Areola
Female Reproductive System
Hormones
 1. Prolactin

 2. Oxytocin
94
MALE
REPRODUCTIVESYS
TEM
A. External genitalia
 Mons pubis

 Penis

Shaft
Glans penis
SHAFT

GLANS
PENIS
PENIS – flaccid most of the time
-Composed of spongy tissues with
many small spaces inside.

ERECTION HAPPENS WHEN…


-
-when excited, arteries dilate,
occluding the vessels, trapping blood
in the spongy tissue.

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99
A. External genitalia
 Scrotum
- wrinkled pouch of
thin skin,
covering a tight
muscle

- Cremasteric reflex
INTERNAL GENITALIA
Male Reproductive System

 Testes
- the male sex glands
or gonads
- 2-3 cm wide that lie

in the scrotum
Male Reproductive System
 parts: TESTES

 ☞ semineferous tubules
☞ Leydig’s / interstitial

cells

☞ Sertoli cells
Male Reproductive System


☞ Epididymis
- approx 20 ft. Long

 ☞ Vas deferens / Ductus


deference
- passage way for
sperm
Male Reproductive System


☞ Ejaculatory duct
 - allows the sperm to
enter the urethra and
then exit the body


ACCESSORY
STRUCTURES
Male Reproductive System
B. Internal genitalia (cont…)
 ☞ Seminal vesicles
 - located along the lower
 posterior surface of the
 bladder
 - 30%
 - Fructose
 -Prostaglandin
Male Reproductive System
Prostate gland
- surrounds the prostatic

area
- 60%
Male Reproductive System


☞ Bulbourethral Gland /
 Cowper ’ S gland
 - located below the
prostate
 - 5%

Male Reproductive System

6.Ureth
ra

Male Reproductive System

7. Semen
 - thick, whitish fluid ejaculated by the man
during orgasm

SPERM
123
1. This is the distance between the sacral
promontory and the inferior margin of the
symphysis pubis:
A.Biischial Diameter
B.Linea Terminalis
C.Conjugate Vera
D.Diagonal Conjugate

125
2. The hormone that stimulates milk
production is:
A.Oxytocin
B.Prolactin
C.Estrogen
D.Progesterone

126
3. According to WHO, what is the normal
sperm count?
A.20 million to 100 million
B.40 million to 500 million
C.50 million to 700 million
D.100 million to 1 billion

127
4. of seminal fluid is secreted by what part of
the male internal reproductive system?
A.Seminal vesicles
B.Prostate gland
C.Cowper’s gland
D.Cul-de-sac of douglas

128
5. This is an important structure that marks
fetal engagement.
A.Ischial tuberosity
B.Sacral promontory
C.Ischial spine
D.Symphysis pubis

129
Female
Reproductive Cycle
Female Reproductive Cycle
 Follicle stimulating
hormone ( FSH )

Female Reproductive Cycle
 Luteinizing Hormone ( LH )

Female Reproductive Cycle
Sources:
1. Hypothalamus

- produces 2 hormones:
a. FSH-releasing factor (FSH-
RF)
b. LH-releasing factor (LH-RF)

2. Pituitary gland

- produces FSH & LH


Female Reproductive Cycle
 Estrogen
- assists in maturation of ovarian follicle
- stimulates the thickening of
endometrium
- FSH suppression
- responsible for secondary sex characteristics
- stimulates contraction of smooth muscles
Female Reproductive Cycle
 Progesterone
 - increase body temp.
- prepares
 endometrium to
receive &
 nourish fertilized
ovum
 - maintains pregnancy
Ovarian
Cycle
Ovarian Cycle

Follicular phase

( day 1 - 14 )
- Ovarian follicles mature
under the influence of
FSH & estrogen
- LH surge causes ovulation
Ovarian Cycle

 Ovulation ( day 14 -
15 )

- Ovum is discharged from


mature follicle
Ovarian Cycle

 Luteal phase ( day


15 - 28 )

- Corpus luteum develops


under the influence of
LH

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

-the ability of the


mucus (cervical) to be
stretched between 2
fingers about 12-15 cm
without breaking (clear
& elastic)
- FERNING PATTERN
QUESTION

During the menstrual cycle, ovulation


generally occurs at which of the


following times?

a. 7 days after the last day of


menstruation
b. 14 days after the last day of

menstrual cycle
c. 7 days before the end of

menstruation
d. 14 days before the end of menstrual

cycle
Endometri
al Cycle
Menst Prolife Secret Ischem
rual rative ory ic
MENSTRUAL Estrogen Progesterone If fertilization
FLOW prepares the nourishes the does not occur,
womb womb corpus luteum
Contains 30-

80mL of blood; regresses


accompanied ENDOMETRIU GLANDS
with mucus M BEGINS TO BECOME DEGENERATI
and THICKEN DILATED ON OF
endometrial WITH LINING
sheds
- a woman
GLYCOGEN
loses 11mg of & MUCIN
iron
QUESTION

May, one of your clients asks,
“How much blood do I lose during
menstruation?” which of the
following would be the nurse’s
best response?

a. “Normal blood loss is 500c. “


b. “Normal blood loss is about 1

glass”
c. “Normal blood loss is about ¼

cup”
d. “Normal blood loss is about 1

cup”
FACTS
 Average cycle: 28 days
Average Menstrual period: 5 days

Average Menarche: 11 – 14 y.o.

Precocious Puberty: fast growth before

 reaching 8 in girls and 9 in boys


Average Menopause: 51 y.o.
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21 Sample
22 23 24 25 26 27 28 calendar
29 30 31
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Ovarian Cycle
BASAL BODY
TEMPERATURE
- drops just prior

to ovulation rises
and fluctuates at
higher level after
FAMILY PLANNING
Natural or Fertility
Awareness Methods
- consist of plotting or identifying
particular days during each
menstrual cycle when coitus should
be abstained on fertile period
- no protection from STDs
159
CALENDAR METHOD

Requires a couple to abstain


from coitus on the days of a
menstrual cycle when the
woman is most apt to
conceive .

160
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Regular Cycle
GET THE DAY OF
OVULATION
SUBTRACT 4 AND ADD 4
FROM THE OVULATION
DATE
EXAMPLE: 30 DAY CYLE
30 – 14 = 16TH DAY
162
FIRST DAY OF RMP:
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
IRREGULAR CYCLE
1.RECORD MENSTRUAL CYCLE
FOR 6 MONTHS
2.TAKE NOTE OF THE LONGEST
AND THE SHORTEST CYCLES

167
SHORTEST CYCLE MINUS 18

LONGEST CYCLE MINUS 11

168
EXAMPLE :

LONGEST = 40 DAYS – 11
= 29
SHORTEST = 25 DAYS – 18
= 7

169
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Calendar Method
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Coitus
Interruptus
- withdrawal of penis from vagina
before
ejaculation
- least effective method
* Adv: inexpensive, medically safe
* Disadv: unreliable, interrupts
sexual excitation
Not eliminate risk of STD
174
CONTRACEPTIVES
176
CONDOM

177
MALE CONDOM
Male
 Adv: prevent conception &
transmission of
 STD
 - Available OTC; easily carried
 - Helps maintain erection
longer;
 prevents premature
ejaculation
EFFECTIVITY: 88%

* Disadv: decrease spontaneity &


sensation
 Should be used with vaginal
CONDOM
A latex rubber or synthetic
sheath that is placed over
the erect penis before coitus

181
Female
- Long polyurethane sheath inserted in
vagina with ring at each end.
- Inner ring –(close) covers cervix
- Outer ring – (open) rests against the
vaginal opening
- lubricated w/ spermicide
- inserted anytime before sexual activity
EFFECTIVITY: 85%
Disadv: Aesthetically unappealing,
expensive for frequent use
- May cause allergy 183
CERVICAL CAP
CERVICAL CAP
Made of soft rubber , shaped like a thimble
and fits snugly over the uterine cervix .
Provides protection for up to 48 hours
Cap is half filled with spermicide
Should be inserted 30 minutes before
coitus
Should be left in place 8 - 12 hours but no
longer than 48 hours
Must be fitted individually by a
healthcare provider
EFFECTIVITY : 82 %
Can cause TOXIC SHOCK SYNDROME

 186
DIAPHRAGM
188
DIAPHRAGM
Circular rubber disk that fits over the cervix
and forms a barricade against the entrance
of sperm.
Must be prescribed and fitted initially by a
physician.
In case of pelvic changes happening during
abortion, pregnancy, cervical surgery,
weight gain or weight loss, the woman must
return to the doctor for refitting.
Applied 2 hours before sexual intercourse
Left in place for 6 – 8 hours
 189
I U D
191
- device inserted into uterine cavity preventing
fertilization or implantation
-
A/E: uterine infection, ectopic pregnancy,

spontaneous expulsion of device

192
Intrauterine Device
(IUD)
Small plastic object inserted into the uterus
through the vagina
Must be fitted by a physician
Inserted before the client has had coitus or
after menstrual flow
Woman may feel a sharp cramp as IUD is
being inserted but will not feel it after it is in
place.
NOT RECOMMENDED FOR WOMEN WHO HAVE
NOT BEEN PREGNANT

193
Two Types
PROGESTASERT – with drug reservoir of
progesterone
Effectivity : 98%
Progesterone in PROGESTASERT prevents
ENDOMETRIUM PROLIFERATION
Must be changed yearly

COPPER T380 – with copper
Effectivity: 99%
Copper affects sperm mobility
Must be changed within 8-10 years
194

ADVERSE EFFECTS
PELVIC INFECTION (PID)
SPOTTING
UTERINE CRAMPING
TOXIC SHOCK SYNDROME

195
Warning signs & symptoms - IUD
P
 - Period late (pregnant),abnormal spotting or
bleeding
A - abdominal pain, pain with intercourse
I – infection exposure, abnormal vaginal
discharge
N – not feeling well, fever > 100.4 F, chills
S– string missing, shorter or longer than
usually felt

196
PILLS
known as “THE PILL” or “OCs”
Composed of estrogen and progesterone
Suppresses FSH and LH thereby inhibiting ovulation
Must be prescribed by a physician following a
Papanicolau smear.
EFFECTIVITY : 99.5%
Packaged 21 or 28 pills to a container.
Generally recommended to be taken the first pill on a
SUNDAY
Must be taken consistently
wait for at least 3 MONTHS before she can conceive
can cause deficiencies in VIT C, B6, B12 and B9 (folic
acid)
decrease effectiveness of INSULIN

198
PILLS
CHILDBIRTH – 2 weeks post delivery
POST ABORTION – Sunday following abortion

21 DAYs
TAKE A PILL AT THE SAME TIME EACH DAY
FOR 21 DAYS
MUST NOT TAKE ANY PILLS AFTER 1 WEEK
RESTART AFTER 1 WEEK
MENSTRUATION RETURNS 4 DAYS AFTER
RESTART

199
PILLS

28 DAY pills


21 REAL PILLS; 7 PLACEBO PILLS
START SECOND DISPENSER OF PILLS THE DAY
AFTER FINISHING THE FIRST DISPENSER
NO NEED TO SKIP DAYS

200
COMMON SIDE EFFECTS
NAUSEA
WEIGHT GAIN
HEADACHE
BREAST TENDERNESS
BREAKTHROUGH BLEEDING

201
DISADVANTAGES
Dysmenorrhea due to lack of
ovulation
Premenstrual syndrome
because of increased
progesterone level
PID
Endometrial cancer
Breast disease
202
203
204
MISSED
Missed ONE pill – take
PILLS
active pill as soon as you
remember . Then continue
taking pills daily .
- No additional
contraceptive needed .

205
MISSED
Missed TWO pills – Take 2
PILLS
active ( hormonal ) pills as soon
as possible and then 2 pills the
following day . Then continue the
following day .
Breakthrough bleeding is common .
- Also , use condoms or
abstain from sex until you have
taken active ( hormonal ) pills for
7 days in a row .
206
MISSED
Missed THREE or more pills –
PILLS
discard the pack and begin
pack the following Sunday .
a new

- Use other methods of


contraception for maximum
protection .

207
SURGICAL
PROCEDURES

208
VASECTOMY
210
Vasectomy
surgical ligation of vas deferens terminating sperm
passage
Small incision made in each side of the scrotum
99.9% effective; performed outpatient basis
Nsg. Int:
Signed consent
Resume sex after 1 wk with 2 negative sperm
( after 10-20 ejaculations);
Explain does not interfere with sperm prodxn,
can still achieve full erection; ejaculation of
seminal fluid with no sperm
Mild analgesics & ice pack for pain
 211
TUBAL LIGATION
Tubal Ligation
fallopian tubes surgically ligated or cauterized
through laparoscopy or minilaparotomy
Incision done under the umbilicus
Laparoscope inserted through incision and CO2 is
pumped to lift the abdominal wall
prevents impregnation of ovum by sperm
done after menstruation or before ovulation
provides immediate contraception
Effectivity : 99.9%
Nsg. Int:
Explain that abdominal bloating may occur for
the first 24hrs
resume sex after 2-3 days 213
In a 32 day cyle, the ovulation
usually occurs on the:
A.14th day before the end of the menstrual
cycle
B.18th day before the end of the menstrual
cycle
C.20th day before the end of the menstrual
cycle
D.24th day before the end of the menstrual
cycle

215
Which gland is responsible for
initiating the menstrual cycle?
A.Ovaries
B.APG
C.PPG
D.Hypothalamus

216
The hormone responsible for egg
cell maturation:
A.Luteinizing Hormone
B.Follicle Stimulating Hormone
C.Estrogen
D.Progesterone

217
Menstruation occurs because of
which following mechanism?
A.Increase level of estrogen and progesterone
B.Degeneration of the corpus luteum
C.Increase vascularity of the endothelium
D.Surge of hormone progesterone

218
Fertilization

Implantation
Fertilization / Implantation

life span of ovum– 24- 48 hours


life span of sperm – 48-72 hours
Fertilization / Implantation
 PREFERTILIZATION
FERTILIZATION
After ovulation:
ZONA PELLUCIDA and CORONA
RADIATA appears to increase the
bulk of the ovum

2.5 mL – average amount of sperm
ejaculated
400 million – average number of
sperm per ejaculation
90 seconds – time it takes for the
sperm to reach cervix 223
Fertilization / Implantation

- Before the sperm can


penetrate the ovum,


the cap must be
removed to reveal
sperm binding receptor
sites

- capacitation

The Human Sperm
Fertilization / Implantation
Acrosome Reaction

 Hyaluronidase
  proteolytic enzymes
released
 Zona Pellucida
  protective covering of
the
 ovum
 Corona Radiata
  cells that encircles the
Fertilization / Implantation
2. Conception / fertilization
a. zona reaction

- ovum becomes
impenetrable to other sperm
b. Fertilization

- the beginning of
pregnancy
- the union of ovum and
sperm
Fertilization / Implantation
233
implantation
Fertilization / Implantation

Zygote
- fertilized

ovum to
implantation
- single cell,

the product
of
fertilization
237
Fertilization / Implantation
3. Implantation

a.Blastomere – 2nd day


b.Morula – 3rd day
239
Fertilization / Implantation

c. Blastocyst – 4th day


 - signals differentiation of

embryo
  Trophoblast – outer

portion
  Embryoblast – inner

portion
243
244
DAY 5

ADHESION
246
INVASION
250
EMBRYONIC
MEMBRANES
&

FETAL STRUCTURES
251
IMPLANTATION
APPOSITION – Blastocyst brushes

against endothelium

ADHESION- Blastocyst attaches to


the surface

 INVASION – Blastocyst settles down


 BLASTOCYST -


EMBRYO
252
CHORIONIC VILLI
 MATURED TROPHOBLASTIC LAYER
 PROBING FINGERS
 REACH OUT INTO THE UTERINE
ENDOMETRIUM
 COMES OUT ON 11 TH TO 12 TH DA
 Will eventually form the FETAL SIDE
of the PLACENTA
-

253
TWO LAYERS
1.SYNCYTIOTROPHOBLAST / SYNCYTIAL
LAYER – outer covering; produces HCG,
HPL, ESTROGEN & PROGESTERONE
2.CYTOTROPHOBLAST / LANGHAN’S
LAYER – protects growing embryo from
spirochete such as syphilis

- Disappears on the 20 th to 24 th week.

254
Fertilization / Implantation
A. Embryonic membranes

 1. Chorion
 - offers support to the
sac that
 contains the amnion
 - cover the fetal surface
of the
 placenta & give the
surface its
Fertilization / Implantation
 2. Amnion

- cushions the fetus &
 maintains an even
temperature
 - cells of amnion
produces prostaglandins
and
 amniotic fluid
Fertilization / Implantation
 B. Amniotic fluid
 - slightly yellow
and
 transparent
 - ave. Amt: 800-
1200 ml
 - ph: 7.2 slightly
alkaline

A nursing instructor ask a nursing

student to list the functions of the


amniotic fluid. The student responds
correctly by stating that which of the
following are functions of the amniotic
fluid? EXCEPT.

a.Is a measure of kidney function


b.Surrounds, cushions, & protects the
fetus
c.Maintains the body temperature of
the fetus
Fertilization / Implantation
OLIGOHYDRAMNIOS
amniotic fluid less than 300ml or
no packet on ultrasound larger
than 1cm
POLYHYDRAMNIOS/ HYDRAMNIOS
more than 2000ml amniotic fluid
or pockets of fluid larger than
8cm on ultrasound
PLACENTA
Latin for “PANCAKE”
Arises out of the trophoblastic tissue
Develops on the 3rd week of gestation
Functional on the 12th week
Serves as the fetal lungs, kidneys and GI tract

263
Nurse Kathy explains some of the purposes

of the placenta to a pregnant mother


during a prenatal visit. Nurse Kathy
determines that the mother understands
the teaching when she states that..

a.Cushions & protects the baby


b.Maintains the temperature of the baby
c.Is the way the baby gets food & oxygen
d.Prevents all antibodies & viruses from
passing to the baby
Fertilization / Implantation
2 Functions:
1. Metabolic

function
 - produces
nutrients needed by
the embryo
 - synthesis of
glycogen, cholesterol
& fatty acids
Fertilization / Implantation
1.Endocrine function
- secretes 4 hormones:

a.Human Chorionic Gonadotropin (HCG)


Can be found in the maternal blood and
urine
sustains the life of corpus luteum
causes the corpus luteum to persist to
continue secretion of estrogen &
progesterone
8 weeks during pregnancy – HCG level
decreases due to the placental
production of progesterone
Fertilization / Implantation

b. Human placental Lactogen


(HPL)

 - also called Human


Chorionic
Somatomammotropin
 - promotes normal nutrition
&
 growth of the fetus
 - promotes maternal breast
dev’t
 for lactation
Fertilization / Implantation
c. Estrogen
- “Hormone of women”
- Stimulates mammarian
development and uterine
growth
d. Progesterone

- “HORMONE OF MOTHERS”
- Reduces uterine
contractility
QUESTION
This is a highly

vascular thickened
endometrium that
lines the pregnant
uterus which is the
site of ovum
implantation?

a. Endoderm
b. Decidua
c. Amnion
d. Chorion
Fertilization / Implantation

2 components

of the
placenta:
1. Maternal
- rough/dirty

where it
attaches to
uterus
Fertilization / Implantation
Fetal side - smooth &

shiny
Fertilization / Implantation
 Deciduas = Endometrial
Layer
 a. decidua basalis
 - forms the maternal
side of the placenta
 - underlies the embryo

 b. decidua capsularis
 - overlies the embryo
 - encapsulates the
embryo
275
Fertilization / Implantation

 c. decidua parietalis/
vera
 - lies the rest of
the uterine cavity
 - does not come
in contact with the
277
SCHULTZ DUNCAN
Fertilization / Implantation
D.UMBILICAL

CORD
- “funis”
- Formed from the
amnion and
chorion and
provides a
circulatory
Fertilization / Implantation
D. UMBILICAL CORD

- “funis”
- 53cm long

Fertilization / Implantation

 2 arteries & 1
vein
 “A-V-A”
Fertilization / Implantation

>3 vessels –
Down Syndrome
<3 vessels –

Kidney
Fertilization / Implantation
C. Wharton’s
jelly
- connective

tissue that
surrounds the
blood vessels &
protects the
vessels from
compression
In explaining the development of her baby, you identified in
chronological order of growth of fetus as it occurs in
pregnancy as :
A.Ovum, embryo, zygote, fetus, infant
B.Zygote, ovum, embryo, fetus, infant
C.Ovum, zygote, embryo, fetus, infant
D.Zygote, ovum, fetus, embryo, infant

285
Placenta is the organ that provides exchange of nutrients
and waste products between the mother and the fetus. This
is fully functional on the:
A.3rd week of pregnancy
B.3rd month of pregnancy
C.12th week of pregnancy
D.4th month of gregnancy

286
Once implantation has taken place, the uterine
endothelium is now termed as the:
A.Endometrium
B.Decidua
C.Placenta
D.Langhan’s layer

287
This layer of the chorionic villi is believed to protect the fetus
against Treponema Pallidum and is present only during the
2nd trimester of pregnancy:
A.Langhan’s layer
B.Syncytial layer
C.Amnion
D.Decidua Capsularis
E.
F.

288
To successfully penetrate the walls of a matured ovum, the
sperm cell undergoes capacitation to release what enzyme
that can break the ovum barrier formed by corona radiata
and zona pellucida?
A.Acrosome
B.Hyaluronidase
C.Zona Reaction
D.Seminal Fluid
E.
F.

289
291
FETAL DEVELOPMENT

1st TRIMESTER
2ND TRIMESTER
3RD TRIMESTER
Zygote
* fertilization – 14

days

Embryo
* 14 days – 2

months

Fetus
* 2 months up to

birth
Fetal Development
 Circulatory System

3rd week
– heart beats

4th – 5th week


– heart’s chamber

develop
Fetal Development

Respiratory System

 24th week
 – surfactant
production
Fetal Development
 Renal System

5th week – kidney function


 12th week – urine
formation
 full term - fully develop
kidney
Fetal Development
Neuromuscular System
 11th-12th week
 – fetal movement
 20th week
 – quickening
 24th week
 – responds to sounds
 28th week
 – opens eyes
 full term
 – brain is ¼ the size of an adult’s
brain
Fetal Development
 Gastrointestinal System

 16th week
 – formation of meconium
Fetal Development
 Endocrine System

12th week
– pancreas produces insulin
Fetal Development
 Reproductive System

 8th week – genital


appears
12th week – sex

differentiation
Fetal Development
 Musculoskeletal System

6th week
– development of bones

7th week

– contraction of muscles
Fetal Development
Integumentary System

12th week – lanugo appears


16th week

 – hand & footprints appear


20th week

 – vernix caseosa appears


28th week – lanugo thins

32nd week

 – subcutaneous fats
thickens
Pregnancy
Gravida – woman who is or
has been pregnant
regardless of the length of
pregnancy
Para – number of pregnancies

at which the fetus has


reached the age of viability.
Duration of pregnancy:
= 280 days or
= 40 weeks from the 1st day of LMP
= 9 months

307
Confirmation of
Pregnancy
Confirmation of Pregnancy
A. Presumptive signs
 - least
indicative of
 pregnancy
A. Presumptive signs
 1. Amenorrhea
 - impregnation has
occurred
- stress
- anemia
- strenuous exercise
A. Presumptive signs

 2. Nausea &
vomiting
 - GI disorder
 - emotional
stress
A. Presumptive signs
 3. Frequent Urination

 - @ 3 weeks
 - UTI
A. Presumptive signs

 4. Fatigue
- illness
- overexertion
A. Presumptive signs
 5. Quickening
 Primigravida: 20

weeks
 Multigravida: 16

weeks
 - presence of gas in
intestine may also
stimulate same
sensation
A. Presumptive signs

 6. Pigmentations
 - @ 24th week
Chloasma / melasma
Linea nigra
Striae gravidarum
A. Presumptive signs

 8. Breast changes
- usually noticeable
during 1st pregnancy
- 2 weeks after

implantation of embryo
Confirmation of Pregnancy
 B. Probable Signs

- objective signs
 - signs that can
be
 documented by
the
 examiner
B. Probable Signs
1.
 Abdominal enlargement

2.
 Hegar’s sign
- softening of the lower
 uterine segment
B. Probable Signs
 3. Chadwick’s sign
- bluish discoloration of the
vagina
- rapidly growing uterine

tumor
- at 6th week but easily noted

at 8th week
B. Probable Signs

4. Ballottement
- a sinking and

rebounding of
the fetus in
it’s
surrounding
amniotic fluid

B. Probable Signs
 5. Goodell’s sign
- softening of the cervix
 6. Braxton Hicks’s contraction
- painless,
 palpable
 contractions

B. Probable Signs
 7. Positive pregnancy
test
 - measures the HCG
 secreted by the
chorionic
 villi of implanted
ovum
B. Probable Signs
C. Positive signs
1. Auscultation of fetal
heart
 sounds

16-20 wks

8-10 weeks
C. Positive signs

2. Fetal movements felt by


the
 examiner
 - 24th weeks
ULTRASOUND
PREPARATION FOR TV-UTZ
DRINK 1 – 2 L of water and
don’t urinate before the test

Rationale:

A moderately full bladder
lifts the uterus from behind
pelvis and provides the best 333
C. Positive signs
Visualization of embryo or fetus

Ultrasound
confirms
pregnancy as
early as 5-6
weeks
gestation by
the presence
of 335
gestational
Mrs. Lobres is pregnant & ask the nurse in

the clinic when she be able to begin to feel


her baby move. The nurse responds by
telling Mrs. Lobres that she will start to
note the baby moves at which following
times..

a.14 and 16
b.10 and 12
c.16 and 20
d.20 and 22
Nurse Betty is reviewing the record of

Annie who just been told that a


pregnancy test is positive. The physician
has documented the presence of bluish
discoloration of vulva. Nurse Betty
determines that this sign indicates..

a.Goodells sign
b.Chadwicks sign
c.Hegars sign
d.Ladins sign
Mary ann, a nurse midwife is assessing

Annie for the presence of ballottement. To


make this determination, Mary ann does
which of the following?

a.Assesses the cervix for thinning


b.Auscultates for fetal heart sounds
c.Palpates the abdomen for fetal movement
d.Initiates a gentle upward tap on the
cervix
 Cervical softening and uterine
souffle are classified as which of
the following?

 A. Diagnostic signs
 B. Presumptive signs

 C. Probable signs

 D. Positive signs

339
QUESTION
 During her first prenatal visit, a client
ask a nurse what physiological changes
shed can expect during pregnancy. The
nurse begins the discussion with
presumptive changes of pregnancy. Put the
following presumptive changes in
ascending chronological order.
a. frequent urination

b. breast changes

c. quickening

d. linea nigra, melasma, and striae

gravidarum
e. uterine enlargement in which the uterus

a. b,c,d,e,a b. b,a,e,c,d
can be palpated over c.
theb,a,e,d,c d.b,a,d,e,c
symphysis
Answer
 b. breast changes  2 weeks
a. frequent urination  3 weeks
e. uterine enlargement in

 which the uterus can be


 palpated over the symphysis
 pubis  12 weeks
c. quickening  16-20 weeks
d. linea nigra, melasma, and

striae gravidarum  24 weeks



1. Which of the following can be considered as the
positive sign of pregnancy?
A.Amenorrhea, nausea and vomiting
B.Frequency of urination
C.Braxton Hicks Contraction
D.Fetal outline by sonography

342
2. Quickening is experienced first by multigravida
clients. At what week of gestation do they start to
experience quickening?
A.16th
B.20th
C.24th
D.28th

343
3. When should the nurse expect to hear the FHR
using a fetoscope?
A.2nd week
B.8th week
C.2nd month
D.4th month

344
4. When should the nurse expect to hear FHR using
doppler ultrasound?
A.8th week
B.8th month
C.2nd week
D.4th month

345
5. When is the fetal weight gain the greatest?
A.1st trimester
B.2nd trimester
C.3rd trimester
D.From 4th week up to 16th week of pregnancy

346
6. You were discussing the presumptive, probably and
positive signs of pregnancy to a junior volunteer nurse.
You will know that the volunteer nurse understood your
teachings when the nurse states which of the following?
A.I know that ballotement is a presumptive sign
while braxton hicks contraction is a
probable sign.
B.Quickening is probable sign and visualization
of the fetus using ultrasound is a positive
sign of pregnancy
C.Rebounding of the presenting part when I tap
the cervix is a probable sign and so is
braxton hicks contraction.
347
D.Gooddell sign ,Abdominal enlargement and
7. Your pregnant patient is scheduled for
ultrasound. As part of the preparations for this
procedure, you will instruct the patient to:
A.refrain from eating 6 hours prior to procedure
B.Void before going down to the ultrasound
department to avoid bladder distention
that can affect the visualization of the
uterus
C.Drink 2 L of water before the procedure.
D.Take sedatives before the test to minimize
anxiety
348
Pregnancy

Physiologic Changes
of Pregnancy
Physiologic Changes of Pregnancy

 1. Breasts
 - increase in size &
nodularity
- enlarged Montgomery’s
tubercles
- veins become prominent
- precolostrums can be
expressed from nipples as
early as 12th- 14th weeks
Physiologic Changes of Pregnancy
 2. Uterus
- increase in vascularity
- presence Hegar’s sign

 3. Cervix
- formation of mucus plug or
operculum
- presence of Goodell’s sign
Physiologic Changes of Pregnancy

 4. Vagina
 - Chadwick’s
sign
Physiologic Changes of Pregnancy

5. Cardiovascular System


 - increase in blood
volume
- increase in cardiac
output
 - increase in pulse rate
- varicosities
- supine hypotension
Physiologic Changes of Pregnancy
6. Respiratory System
 - increase O2 demand
- increase chest
 circumference
- displacement of the
diaphragm
Physiologic Changes of Pregnancy
7. Gastrointestinal System

- swollen gums
 (“epulis of pregnancy”) –
ESTROGEN CAUSES HYPEREMIA
- Constipation -
overrelaxation
- Heartburn
- Hemorrhoids
Physiologic Changes of Pregnancy

 8. Urinary System

- urinary frequency
Physiologic Changes of Pregnancy
 9. Musculoskeletal System
 - Lordosis
 - Characteristic
waddle
- Diastasis recti –
longitudinal muscles
separate
Physiologic Changes of Pregnancy
 10. Integumentary System

 - Chloasma/ Melasma
- Linea Negra
- Striae Gravidarum
Physiologic Changes of Pregnancy
 11. Endocrine System
 - increase activity &
hormone production –
pituitary gland increase in size

- slight hyperparathyroidism
- enlargement of the thyroid
gland
- increase melanocyte
 When talking with a pregnant client who is
experiencing aching swollen, leg veins,
the nurse would explain that this is most
probably the result of which of the
following?

 A. Thrombophlebitis
 B. Pregnancy-induced hypertension
 C. Pressure on blood vessels from the
enlarging uterus
 D. The force of gravity pulling down on the
uterus

362
Pregnancy
Psychologic
Changes of
Pregnancy
Psychologic Changes of Pregnancy
 PREGNANCY: maturational crisis
 1. First Trimester
 - ambivalence

- Fear
- Fantasies about dreamchild
- possible decrease in sex drive
- FOCUS : SELF
Psychologic Changes of Pregnancy
 First Trimester

 TASK:
 Accepting the
pregnancy,
 “I am pregnant”

Psychologic Changes of Pregnancy
 2. Second Trimester
 - alternate feelings of
emotional well being &
lability
 - possible increase in sex
drive
 - adjustment to change in
body image
FOCUS: FETUS
Psychologic Changes of Pregnancy

 Second Trimester

TASK:
Accepting the baby, “A

baby is growing inside


me”
Psychologic Changes of Pregnancy
3. Third Trimester
- feelings of awkwardness &

clumsiness
- renewed fears & tension
about labor
- - nightmares about
deformed babies
- spurt of energy during the

last month “nesting


instincts”
Psychologic Changes of Pregnancy

 Third Trimester
 TASK:
 Preparing for
parenthood,
 “I am a mother”

370
371
Psychologic Changes of
Pregnancy
COUVADE SYNDROME

Group of
physiologica
l&
behavioral
manifestatio
n
experienced
by the
husband 372
Pregnancy

Antepartum
Assessment
& Care
Antepartum Assessment & Care
 ESTIMATES
a. EDD
NAEGEL ’S RULE – if LMP is
JANUARY TO MARCH

 - Add 9 months
 - add 7 days

- Don’t change the year


Antepartum Assessment & Care
 ESTIMATES
a. EDD
NAEGEL ’S RULE – if LMP is
APRIL TO DECEMBER

 - subtract 3 months
 - add 7 days

- change the year


A pregnant clients normal
menstrual period began on July
30. using Naegele’s Rule, what
is her estimated due date?

a.April 23
b.April 30
c.May 7
d.May 23

376
Antepartum Assessment & Care
 Fetal Length
 HAASE’S RULE
- 1 to 5 months
 (multiply the age of
pregnancy by itself)
ex: 4 months x 4 = 16 cm
Antepartum Assessment & Care
 Haase’s rule

- 6 to 9 months
(multiply the age of

prgnancy by 5)

 ex: 6 months x 5 = 30 cm
Antepartum Assessment & Care
 Mc Donald’s rule


Antepartum Assessment & Care
 Mc Donald’s rule
- Lunar months



Fundal height(cm) x 2/7
 ex: 14 cm x 2/7 = 4
months
- Weeks:

 Fundal height (cm) x

8/7
 ex: 14 cm x 8/7 = 16

weeks

Antepartum Assessment & Care
 AGE OF GESTATION –
number of days since LMP to
the present day divided by 7

LMP – December 16, 2004


Present day – February 14,

2005
DECEMBER – 15 (31 DAYS – 16 DAYS)
JANUARY - 31
FEBRUARY - 14
---------------------
 60 / 7

8 WEEKS AND 4 DAYS

382
Antepartum Assessment & Care
 D. Obstetric history

 G - # of pregnancy
 T –between 37 – 42 weeks
 P – pregnancies before 37
weeks
 A – pregnancy below 20weeks
 L – # of currently living
children
Following confirmation of pregnancy,
the client has come into the clinic for
her first prenatal visit. She reports
having a 5 year old child who was
born at 40 weeks gestation, a set of
3 year old triplets who were born at
34 weeks gestation, & a first
trimester abortion when she was in
college. On her medical record, the
nurse would make which of the
following entries?

a.Gravida 4, Para 1114


b.Gravida 3, Para 1314
c.Gravida 4, Para 4014 384
When taking an obstetrical history on a
pregnant client who states, “I had a son
born at 38 weeks gestation, a daughter born
at 30 weeks gestation and I lost a baby at
about 8 weeks,” the nurse should record
her obstetrical history as which of the
following?
A. G2 T2 P0 A0 L2
B. G3 T1 P1 A0 L2
C. G3 T2 P0 A0 L2
D. G4 T1 P1 A1 L2
385
A nurse is collecting data during an
admission assessment of a client
who is pregnant with twins. The
client has a healthy 5 year old child
that was delivered at 38 weeks &
tells the nurse that she does not
have a history of any type of
abortion or fetal demise. The nurse
would document the GTPAL for this
client as

a.G=3, T=2, P=0, A=0, L=1


b.G=2, T=1, P=0, A=0, L=1
c.G=1, T=1, P=1, A=0, L=1
d.G=2, T=0, P=0, A=0, L=1
Antepartum Assessment & Care
Fundal Heights:

 BARTHOLOMEW’S RULE
IMPORTANT LANDMARKS

12WKS – Slightly above symphyis


pubis
20 WKS – level of the umbilicus
36 WKS – below the xiphoid process
32 AND 40 WKS – same level

389
 A nurse is performing an assessment on a
client who is at 16 weeks of gestation. The
nurse expects to note uterine height to be
at which location?

a.Between xiphoid process & umbilicus


b.Umbilicus
c.Symphysis pubis
d.Between umbilicus & symphysis pubis
Prenatal Teaching
I. SCHEDULE OF VISITS

EVERY MONTH – From the time pregnancy
until the 7th month
TWICE A MONTH / EVERY 2 WEEKS – 8th
month
WEEKLY – 9th month
2X A WEEK - Post Partum or >42wks

391
MEMORY AID
1st - 7th month– EVERY
MONTH
8th month – TWICE A MONTH
9th month– EVERY WEEK
POST TERM – TWICE A WEEK

392
1. A 28 year old primigravida who is in her 1st trimester of
pregnancy says to the nurse, "I was so anxious to be
pregnant." The nurse would respond appropriately based on
an understanding of which true statement?
A.Having mixed feelings in the first trimester
increases the chances of poor postpartum
bonding.
B.Having mixed feelings about pregnancy is
normal in the first trimester.
C.Women who are uncertain about wanting to
be pregnant should be told of the options
available to them.
D.Women who are uncertain about wanting to
be pregnant need counseling to enable
them to deal with their femininity. 393
2. A client in the first trimester complains of nausea every
morning and asks about medicine to prevent it. What is the
nurse's most helpful response?
A.Let me tell you about some methods to
control nausea without medication
B.You shouldn’t take medication during
pregnancy especially during the early
weeks.
C.I’ll ask the physician if you can have
something.
D.You’ll probably have a lot less nausea in just a
few weeks.

394
3. Mrs Adams is expecting her third child. Her other children,
both born at term, are ages 2 and 5. Mrs adams has had an
abortion. Mrs Adams gravida/para status is:
A.Gravida 2, para 2102
B.Gravida 4, para 2012
C.Gravida 3, para 2012
D.Gravida 4, para 2002

395
4. Ungta came to your prenatal clinic for her first prenatal check
up. You asked about her obstetric history. She informed you that
she gave birth to a set of quadruplets who were born at 32 wks
AOG 2 years ago. She also has a 5 year old son who was born at
41 wks AOG. She also recalled having been pregnant in college
but the oregnancy was terminated at 19 wks AOG.

A.Gravida 7, Para 1205


B.Gravida 4, Para 1115
C.Gravida 7, Para 1415
D.Gravida 3, Para 1115

396
5. You are assigned to get the expected date of delivery for
Patient Emma whose LMP was April 16, 2010.

A.January 23, 2011


B.January 23, 2010
C.July 10, 2011
D.January 24, 2011
E.
F.

397
6. Riza, your friend, asked you how many weeks pregnant she is.
You asked her about her last menstrual period. She answered,
"January 18, 2010". The date today is October 13, 2010.

A.
2.?
3.?
4.?
5.?
6.Answer: 38 2/7 wks
G.
398
6. Babe, a pregnant client from Brgy. Bata, wanted to know her
age of gestation. She does not know the first day of her last
menstrual period. You measured her fundic height and it was
18cm. In lunar months, how many months pregnant is your
patient?

A.
2.?
3.?
4.?
5.?
6.Answer: 5 months
G.
399
Stella is 33 weeks pregnant. She asked you about her prenatal
visits. As a nurse, you know that at this stage of pregnancy, she is
supposed to visit the doctor:

A.2x a month
B.Once a month
C.Every week
D.3x a month

400
When teaching Aling Julia about her pregnancy, you
should include personal discomforts. Which of the
following is an indication for prompt professional
supervision?

A.Constipation and hemorrhoids


B.Backache
C.Facial Edema
D.Frequent urination

401
Edelweiss is very concerned because she is
constantly dreaming about her baby being born
without limbs. She asked you if this can cause
congenital defects to the baby. You will base your
answer in your knowledge that:
A.This is just normal for mothers who are in
their 3rd trimester of pregnancy.
B.She is probably worrying too much. Advise
her to stop watching horror movies as this
can cause unwanted stress in the baby.
C.This is related to staying up late at night.
Suggest sleeping at an early time.
D.Tell your patient to see the doctor
immediately as this is one warning sign of 402
Laborator y Tests
Antepartum Assessment & Care

 1. Blood grouping
 - to determine the blood
type
2. Hgb/Hct

 - to detect anemia
 - Hgb < 11 g/dl or Hct <
32%
Antepartum Assessment & Care
3. CBC

- to detect infection or cell


abnormalities
- RBC – 4.2 – 5.4 million/uL
- 4.6 – 6.2 million / uL
 WBC – 5,000 – 10,000
cells/mcL
Antepartum Assessment & Care
4. Rh factor
- for possible maternal-fetal

blood incompatibility

5. VDRL
- syphilis screening
OPOLDS
NEUVER
ANEUVER
Antepartum Assessment &
Care
 Leopold ’ s maneuver
 - a systematic way of
observation & palpation to
determine fetal position

Antepartum Assessment &
Care

 Preparation:

1. Let the patient void.


2. Position the mother

supine with knees flexed


STEP 1
Antepartum Assessment &
Care

Steps:

1.Palpate what is lying in the


fundus
Breech – round, hard, mobile
Cephalic – irregular, soft,
nonmobile
1.
FETAL PRESENTATION
Antepartum Assessment & Care

2. Palpate fetal


back in relation to
the right & the
left
FETAL POSITION


STEP 2
Antepartum Assessment & Care

 3. Locate
presenting part @
pelvic inlet & check
for engagement
 FETAL ENGAGEMENT
STEP 3
Antepartum Assessment &
Care

4.Palpate just above the


inguinal the
relationship of the
presenting part to
the pelvis
 FETAL ATTITUDE
STEP 4
Antepartum Assessment & Care
 Assessing the fetal heart
tones
1. Fetal heart tones
- A very rapid, somewhat

muffled ticking sound


- normal: 120-160 bpm
Antepartum Assessment &
Care
2. Uterine bruit/ Souffle
- a soft murmur caused

by the passage of blood


thru the uterine vessels
- synchronous with

maternal pulse
Antepartum Assessment & Care
 3. Funic Souffle
- hissing sound produced
by passage of blood thru
the umbilical arteries
- synchronous with FHB


VARIATIONS IN
FETAL HEART BEAT
Antepartum Assessment & Care

 1. Early deceleration
 - caused by fetal head
compression

 mgt: no intervention required


Antepartum Assessment & Care

 2. Late Deceleration

 - caused by uteroplacental
 insufficiency
mgt: change the woman’s

position (supine to lateral) to


left side/trendelenburg; O2
administration; NOTIFY
Antepartum Assessment & Care

 3. Variable Deceleration

- caused by umbilical cord


 compression

- mgt: change the woman’s


position (supine to lateral /
trendelenburg)
 to relieve pressure on the
cord
Pregnancy
Assessment
of Fetal
Maturity and
Well Being
Assessment of Fetal Maturity and
Well Being
 AMNIOCENTES
-IS
aspiration of
fluid from the
pregnant uterus
for examination.
AMNIOCENTES
IS
433
Assessment of Fetal Maturity and
Well Being
Preparations:

- Let the patient void


- supine position attached to the

sonogram
- Take baseline Maternal BP and FHR
- -skin is cleaned with betadine
- - gauge 22 needle then inserted
- - doctor obtains 15 – 20 cc of fluid
Assessment of Fetal Maturity and
Well Being
 early 1st trimester:
 to detect congenital

abnormalities
 3rd trimester:
 determine fetal lung

maturity

Assessment of Fetal Maturity and
Well Being
 Lecithin /
Spingomyelin (L/S)
Ratio
 - the protein component
of the enzyme surfactant
 Normal Ratio 2:1
Assessment of Fetal Maturity and
Well Being
 Alpha-Feto Protein
- major plasma of early

fetus
- decrease after 13

weeks of gestation
- with AFP: N.T.D
- Normal level: 38-45
Assessment of Fetal Maturity and
Well Being

 POST AMNIOCENTESIS:
- Let the mother drink 2-4
glasses of water within 2
hours
- Monitor vital signs
A woman who is 15 weeks pregnant comes

to the clinic for amniocentesis. The nurse


knows that this test can be used to identify
which of the following characteristics or
problems? EXCEPT.

a. fetal lung maturity


b. chromosomal defects

c. neural tube defects

d. sex of the fetus

440
Non Stress Test
Assessment of Fetal Maturity and
Well Being
 NON STRESS TEST (NST)
- whether an INCREASE in
FHR occurs when there is
INCREASE in movement
- non stress because the fetus is
not challenged or stressed by
uterine contractions
NON STRESS TEST (NST)
Assessment of Fetal Maturity and
Well Being
Indications:

 a. women with prolonged


pregnancy
b. diabetes

c. hypertensive disorders


d. history of stillbirth
Assessment of Fetal Maturity and
Well Being
 Interpretation:
REACTIVE:
• FHR greater than 15 bpm in

response to fetal activity


• 5 such responses in 20 minute

recording
Assessment of Fetal Maturity and
Well Being
 NON-REACTIVE:
• FHR does not increase
to fetal activity
• Less than 3 responses in

20 minute recording
OXYTOCIN
CHALENGE TEST
Assessment of Fetal Maturity and Well
Being

OXYTOCIN CHALLENGE TEST


(OCT) /
CONTRACTIONS STRESS TEST

(CST)
- done for evaluation of the

ability of the fetus to


withstand the stress of uterine
contractions
Assessment of Fetal Maturity and
Well Being
Indication:

☞ If the woman has a non

reactive non stress test


Procedure:
☞ Diluted IV Oxytocin is

given via infusion pump


Assessment of Fetal Maturity and
Well Being
Interpretation:
☞ Negative:

 3 contractions of good
quality

 ☞ No Late Deceleration
Assessment of Fetal Maturity and
Well Being

☞ Positive:

 presence of Late Deceleration in

response to uterine
contractions

☞ Indicates Placental

Insufficency
A client at term arrives in the labor room experiencing
contractions every 4 minutes. While she is in active labor, the
EFM registers a pattern indicating variable deceleration. Which
nursing intervention should be initiated first?

A.Monitor blood pressure every 2 minutes


B.Change maternal position
C.Increase IVF rate
D.Prepare for an immediate CS

452
While monitoring fetal heart tones in a client who is in active
labor, the nurse notes early decelerations. The nurse should:

A.Start oxygen at 2L/minute


B.Continue to monitor fetal heart tones
C.Change maternal position
D.Notify physician

453
A woman who is in her 35th week of gestation when she comes
to the clinic. Which of these statements requires further
investigation?

A.I’m going to the bathroom much more


frequently.
B.I’m having trouble climbing the two flights of
steps to my apartment.
C.I can’t seem to get the rings off my finger.
D.My back aches a lot more than it did.

454
To determine fetal presentation using Leopold's
maneuver, the first maneuver is to:

A.Determine degree of cephalic flexion and


engagement.
B.Determine part of fetus presenting into pelvis
C.Locate the arms, back and legs
D.Determine what part of fetus is in the fundus

455
Beforethe start of a nonstress test, the FHR is 120 bpm. The
mother ate snacks and the practitioner noticed an increase
from 120 to 137bpm for 15 seconds. The same results were
taken 7x for the entire duration of the procedure. How would
you read the result?

A.Abnormal
B.Non reactive
C.Reactive
D.Inconclusive, needs repeat

456
You noted in the patient's chart that her maternal serum AFP
level was only 35ng/mL. As a knowledgeable nurse, you can
expect that this result indicates:

A.Neural tube defects


B.Chromosomal abberation
C.That this is a normal result
D.Respiratory distress

457
Which of the following mothers needs Rhogam?

A.Rh+ mother who delivered an Rh- baby.


B.RH- mother who delivered an Rh + baby.
C.Rh+ mother who delivered an Rh+ baby.
D.Rh- mother who delivered an Rh- baby.

458
Priority intervention for a client who just underwent
amniocentesis is:

A.Hydration by giving 2 glasses of water after


the procedure
B.Pain relief by offering prescribed analgesics
C.Oxygenation by administering 2L of oxygen to
prevent fetal distress
D.Xray to check for accidental bladder puncture

459
The 4th leopold maneuver is done to determine:

A.Fetal presentation
B.Fetal position
C.Fetal engagement
D.Fetal attitude

460
Pregnancy
Health Education
 1. Weight gain
 Normal weight
2-5 lbs – 1st trimester
1 lb/week – 2nd & 3rd
trimester
Total Weight Gain: 25-35 lbs
Third Trimester – gains most

weight b/c fetus is laying down


fat deposits
Health Education
2. Nutrition

Calories – increase 300 K cal/day; 2


tall glasses of milk
CHON – 4 servings of meat
recommended or 60 g/day; cooked lean
meat
Ca – 1200 mg/day
Folate – 400 mg/day; orange juice,
spinach and legumes
Iron – 30 mg/day
 A nurse is instructing a pregnant client
regarding measures to increase iron in
the diet. The nurse tells the client to
consume which food that contains the
highest source of dietary iron?

a.Milk
b.Potatoes
c.Cantaloupe
d.Dark green, leafy vegetables
Health Education
 Rest
- encourage
mother to sit down
& elevate the feet
- 10 hours of sleep
EXERCISES
Health Education
 a. Walking – most ideal exercise
stimulates muscular activity of the
entire body & does not result in
fatigue or strain.
 b. Kegels exercise

Health Education
Health Education
 c. Tailor sitting
 - stretches perineal
muscles

Common
Discomforts of
Pregnancy
Discomforts of Pregnancy
 a. nausea & vomiting
Mgt:
eat crackers before arising in

morning
 eat small frequent meals

 avoid fried, greasy, spicy foods

 avoid foods with strong odors


Discomforts of Pregnancy

b. heartburn

Mgt:
 eat small, several meals

 avoid smoking & coffee;

cucumbers & radishes


 sit upright especially after meals
Discomforts of Pregnancy
 c. constipation
 Mgt:
 drink at least 8 glasses of H20 a day
 increase fiber in diet

 exercise

 establish a regular pattern of elimination


Discomforts of Pregnancy
 d. Varicosities

Mgt:
 avoid constricting clothing

 avoid crossing legs at the knees

 take frequent rest periods with legs

elevated
 wear support hose or elastic stockings
Discomforts of Pregnancy

 e. frequent urination
Mgt:
 will be resolved without

intervention
 Kegels exercise
Discomforts of Pregnancy
f. backache
Mgt:

 tailor sitting
 squat rather than bend
when lifting
Discomforts of Pregnancy
 g. Leukorrhea
Mgt:
 wear perineal pads

 clean perineal area always


Discomforts of Pregnancy
 h. Hypotension
 Mgt:
 Left side lying position
Discomforts of Pregnancy
 i. Dyspnea

 Mgt:
 elevate head of bed
Pregnancy
Danger
Signs of
Pregnancy
Danger Signs
a. vaginal spotting/bleeding
b. leaking of fluid from the

vagina
c. unusual abdominal cramps

 ✔ 1st trimester :

 ✔ 3rd trimester :

d. persistent headache, blurring

of vision
Danger Signs

e. marked swelling of hands &


feet
f. painful, burning urination

discharge
g. foul smelling vaginal

discharge
h. chills & fever

i. persistent nausea & vomiting


Labor
and
Delivery
Labor and Delivery
Theories
Labor and Delivery

1. Uterine Stretch
- as the uterus becomes

stretched, pressure
increases & physiologic
changes occurs
 - initiation of labor
Labor and Delivery

 3. Progesterone deprivation
 - decrease level of
progesterone results to
smooth muscle contraction
Labor and Delivery

 2. Oxytocin
 - as pregnancy
progresses, uterus
becomes more sensitive
to oxytocin
Labor and Delivery
 4. Prostaglandin cascade
 - there is an increase level of
prostaglandin during the
late month of pregnancy
results to uterine
contraction
Labor and Delivery
Mechanics
Passage
Nurse Jordan should explain to his pregnant

client that the type of pelvis most favorable for


labor & birth process is?

a.Android pelvis
b.Gynecoid pelvis - heart shape pelvic inlet
c.Anthropoid pelvis - round shape pelvic inlet
d.Platypeloid pelvis - oval shape pelvic inlet
-reverse oval shape pelvic
inlet
Labor and Delivery
 1. Passage

 Gynecoid
- normal female pelvis
- ideal for childbirth
- round shape pelvic inlet
Labor and Delivery

 Android
- male pelvis
- heart shaped pelvic inlet

Labor and Delivery

 Anthropoid

- “ape like” pelvis

- oval shaped pelvic
inlet
Labor and Delivery

 Platypeloid
- flattened pelvis
- reverse oval shaped


Passenger
Labor and Delivery
2. Passenger

(96% cephalic presentation)

a.Fetal bones
- 2 frontal bones
- 2 parietal bones
- occipital bone
 (bones that are involved in birth process)
FRONTAL
PARIETAL
OCCIPITAL
Labor and Delivery

Suture lines
- strong but flexible tissue that

connects 5 major bones



☞ coronal suture
☞ saguittal suture
☞ lambdoidal suture
☞ frontal suture
SUTURES
Labor and Delivery

Fontanels
- spaces @ the intersection

connecting the skull


✔ anterior fontanel – diamond
shape
✔ posterior fontanel – inverted

triangle
FONTANELS
Fetal Lie
Labor and Delivery


Fetal lie
 - comparison of the long
axis of the fetus to the
long axis of the mother
LONGITUDINAL
TRANSVERSE

514
Fetal Attitude
Labor and Delivery

Fetal attitude
- relationship of fetal parts to

each other
✔ good flexion – fully
flexed
✔ moderate flexion -

neutral
✔ poor flexion -
Fetal Presentation
Labor and Delivery

Fetal Presentation
- relationship of presenting

part to the mother’s


cervix

1. Cephalic
 - most favorable
presentation
Labor and Delivery


Reasons:
a. largest single fetal part

b. can gradually change

shape
c. fetal head is smooth,

round
Labor and Delivery
 Types of Cephalic
Presentation

a. Ver tex
 - most common

- fetal head fully flexed


- Occiput and posterior
fontanel is palpated
during IE
Labor and Delivery

b. Militar y

- fetal head is in neutral


position
Labor and Delivery

c. Brow

- fetal head is partly


extended
- Unstable
- Fetal forehead and
anterior fontanel is
palpated during IE
Labor and Delivery

d. Face

 - poor flexion
- complete extension of
all
 body parts
Labor and Delivery


2. Breech

Disadvantages:
 less effective in dilating

cervix
 fetal head is the last part to

come out
528
Labor and Delivery
 3 Variations:

a. Fr ank Br eech
 - most common

 - hips are flexed but the

knees are extended to rest


on the chest
 - the buttocks alone present

to the cervix
Labor and Delivery


b. Complete breech

- the fetus has thighs tightly


flexed on the abdomen
- both the buttocks & the tightly

flexed feet present to the cervix


Labor and Delivery

c. Footling

 - one foot presents:


 Single Footling
 - if both present:
 Double Footling
SINGLE DOUBLE
Labor and Delivery


3. Shoulder/ Transverse
Presentation

 - the shoulders is in
transverse lie

Fetal Position
Labor and Delivery


h. Fetal Position
 - relationship of fetal presenting
parts to the mother’s pelvic
quadrants
Position/Presentation/Variety
 3 Letters

1st letter: landmark pointing to


mother’s R or L
2nd letter: fetal landmark (O,M,Sa,)
3rd letter: landmark points (A,P,T)

541
P

R L

A
543
LOA ROA
545
546
547
548
Occiput Anterior
Best and most common position
for the baby during lab
Occiput Posterior
Baby’s head during descent
will rotate to assume a
favorable position for
successful delivery.
- Pressure on sacral nerves –
BACK LABOR 549
A woman comes to the physicians office for a
routine prenatal check up at 34 weeks
gestation. Abdominal palpation reveals the
fetal position as right occiput anterior
(ROA). At which of the ff sites would the
nurse expect to find the fetal heart tone?

a.Below the umbilicus, on the mothers left


side
b.Below the umbilicus, on the mothers right
side
c.Above the umbilicus, on the mothers left
side
d.Above the umbilicus, on the mothers right 550
side
Fetal Station
Labor and Delivery

g. Fetal station
- the relationship of the presenting
part to the level of the ischial
parts
-
 -3 - floating: 3cm above
-2 - floating: 2cm above
-1 floating: 1 cm above
0 - ischial spine: engaged

+1 - 1cm below the ischial spine


+2 - 2cm below the ischial spine


+3 - 3cm below the ischial spine
Power
Labor and Delivery
 A. Phases
 1. Increment

 - the beginning

of contraction
Labor and Delivery
A.Phases
 2. Acme/ Peak
 - period in which

contraction is most
intense
Labor and Delivery

A.Phases
 3. Decrement

 - period of

descending
intensity
Labor and Delivery

 B. Assessment

1. Fr equency
- expressed in minutes (3-4

mins)
frequency
Labor and Delivery


2. Dur ation
- express in seconds : 30

secs
duration
Labor and Delivery

3. Inter val/ Relaxation

 - period between the


end of 1 contraction &
the beginning of the
next
interval
Labor and Delivery

4. Intensity

- strength of contractions

- express in mild, moderate, strong


mild (uterine muscle is somewhat
tense)
moderate (uterine muscle is
moderately tense)
or strong (uterine muscle is
boardlike).

Labor and Delivery


5. PSYCHE
- mental preparation of the

mother for labor &


delivery
 a. marked anxiety or
fear
b. relaxation
Determine the fetal position.

Answer: Left occiput posterior 569


During labor, meconium in the amniotic fluid is a
normal finding in which of the following situations?

A.Preterm labor
B.Cephalopelvic disproportion
C.Prolonged latent phase
D.Breech presentation

570
Before becoming pregnant, Ruffa weighed 120 lbs. She
is now on her 24th week of pregnancy and she now
weighs 138 lbs. You will give your health teachings to
Ruffa based on your knowledge that:
A.This is just normal for a woman who is on
her 24th week of pregnancy
B.A total of 18 lbs added to the previous weight
is a sign of PIH. Consult the doctor.
C.She needs to cut her intake of fat as this is
considered overweight for her week of
pregnancy
D.She needs to eat more to reach the required
minimum weight for women who are in
their 24th week of pregnancy.
E.
F. 571
A woman you meet is instructed in preparation for childbirth. She
asks why tailor sitting is recommended as an exercise for
pregnancy. Your best response would be that it:

A.Improves the blood supply to the uterus


B.Strengthens the abdominal muscles
C.Decrease respiratory effort
D.Stretches perineal muscles
E.

572
This is a period that marks the start of one contraction to
the end of the same contraction.
A.Intensity
B.Frequency
C.Duration
D.Interval
E.

573
Mylene is nearing the term of her pregnancy. Her husband,
Michael, expressed concern over her wife's awkward duck-like
walk. As a nurse, you are going to tell the husband that:
A.“One hormone in pregnancy causes relaxation of
the pelvic muscles thus the characteristic gait of
your wife. This is normal.”
B.“Because your wife’s abdomen is getting bigger,
she needs to lower her center of gravity by
walking that way.”
C.She must have been watching a lot of cartoons
lately.
D.This is her way to catch your attention because you
seem to be overly concerned about the baby.
E.
F. 574
Upon internal examination, you palpated a soft surface over the
fetal head which you have later determined to be the anterior
fontanel. You also felt the fetal forehead. Using your obstetric
knowledge, you can conclude that the fetal presentation and
attitude is:
A.Cephalic Face presentation
B.Cephalic Vertex presentation
C.Cephalic Brow Presentation
D.Cephalic Military Presentation

575
Pregnancy

Preparati
on for
Labor and Delivery

1. Dick – Read
- slow abdominal breathing
in early labor & rapid chest
breathing in advance labor


2. Br adley
- include the father as a
support person for
 “husband-coached
childbirth”
579
580
Labor and Delivery

3. Le Boyer

 - views birth as a
traumatic experience
for the neonate
DELIVERY ROOM
Labor and Delivery

4. Lamaze
 “psychoprophylaxis”
- it uses the mind to prevent
pain
- DELIVERY without the use of
analgesia
- In case of pain: check
maternal BP and FHR in
response to contractions
- support person: a husband
or a coach
Signs of
Impending
Labor
Signs of Impending Labor

Lightening
- settling of the fetus
 in the lower uterine
 Segment

 - effects:
• breathing becomes easier
 • urinary frequency
 • lordosis
Signs of Impending Labor

2. Bur st of ener gy

 - called “nesting”, the


pregnant woman is busy
preparing the things of her
baby
Signs of Impending Labor

3. Blood Show

4. Ruptured BOW

True
Labor
Labor True False
Contractions REGULAR, BECOMES IRREGULAR & NOT
MORE FREQUENT, INTENSE
GRADUAL INCREASE
INDURATION &
Discomforts BEGINS AT THE
INTENSITY PRIMARILY ON THE
LOWER BACK & ABDOMEN ONLY
RADIATES AROUND
ABDOMEN
Effects of Walking CONTRACTIONS ARE CONTRACTIONS MAY
INTENSIFIED WHEN DECREASE OR
WALKING DISAPPEAR WHEN
WALKING

Cervical changes PROGRESSIVE NO CERVICAL


DILATATION & CHANGES
EFFACEMENT
- TRUEST INDICATOR
D F IR

CARDINAL MOVEMENTS

E - ER - E
Cardinal Movements
A. Enga gement

- Fetal presenting part has


passed the pelvic inlet.
- - station ‘0’
Cardinal Movements

B . Descent

 - downward movement of
the biparietal diameter of
the fetal head to within
the pelvic inlet
Cardinal Movements


C . Flexion
 - baby moves further
downward & then head
meets obstruction at the
pelvic floor causing flexion
FLEXION
Cardinal Movements
 C. Internal Rotation

- for the head to pass the pelvic outlet


- the head flexes as it touches the pelvic
floor
- the occiput rotates until it is suspended,
or just below the symphysis pubis,
bringing the head into the outlet of the
pelvis
INTERNAL ROTATION
Cardinal Movements
D. Extension

- occurs as the fetal head passes


beneath the symphysis pubis
- after internal rotation, head of the
baby extends with position still
the same so that the face & neck
can come out
EXTENSION
Cardinal Movements
E. External Rotation

- almost immediately after the


infant’s head is born, the head


rotates back into the diagonal
or transverse position to deliver
the shoulders
EXTERNAL ROTATION
Cardinal Movements
 F. Expulsion
 - once the shoulders are
delivered, the rest of the
baby is delivered easily &
smoothly because of its
smaller size
EXPULSION
Stages of
LABOR
First Stage

STAGES OF
DILATATION
A. First Stage (Stage of Dilatation)
 • onset of true labor to full cervical
dilatation
 3 Phases:
1. Latent Phase

Dilation
 0 - 3cm dilatation

Frequency 10 min apart contraction

Duration 20-40 seconds duration


A. First Stage (Stage of Dilatation)
 Mgt:
1. encourage ambulation

2. check V/S, FHR, contraction

3. clear fluids or ice chips

4. left-side lying position

5. breathing techniques:

slow, deep chest or


 abdominal breathing
6. encourage voiding Q2H

7. Patient is talkative; mild-moderate

contraction
A. First Stage (Stage of Dilatation)

2. Active Phase

Dilation 4-7 cm dilation

Frequency 2-5 min apart contractions

Duration 40-60 seconds duration


A. First Stage (Stage of Dilatation)
 Mgt:

1.check V/S, FHR, contractions


2. calm environment
3. comfort measures
•back rub or effleurage
•side lying position
4. breathing techniques:
accelerated slow panting
6. IVF

7. provide psychosocial support


8. Patient is serious ; moderate to

strong contractions
A. First Stage (Stage of Dilatation)


3. Transition Phase

Dilation 8-10 cm dilation

Frequency 1.5 to 2 mins apart contractions

Duration 60-90 seconds duration


A. First Stage (Stage of Dilatation)
 Mgt:
1. check V/S, FHR, contractions
2. I.E.
3. avoid pushing
4. provide short, concise information
5. breathing technique: (to prevent from
pushing when not completely dilated):

 high – chest, pant-blow


6. nausea & vomiting may occur

7. Patient is uncontrollable; strong

contractions
Second Stage (Stage of Expulsion)
Mgt:
1. check V/S, FHR,
contractions
2. I.E.
IMMINENT DELIVERY
CROWNING – PERINEUM IS THIN,
BULGING AND STRETCHING

CLIENT has uncontrollable urge


to bear down

617
3. positioning
Second Stage (Stage of Expulsion)
4. perineal

pr eparation
Second Stage (Stage of Expulsion)
5. Breathing technique:

- 2 shor t br eaths, hold 3r d


br eath w hile pushing
- never open mouth
6. Catheterization
7. Episiotomy

8. Give Oxytocin IV after

delivery (monitor FHR while


administering)
7. Episiotomy
Second Stage (Stage of Expulsion)
Purposes:
a.to avoid laceration of
the perineum
b.to shorten the 2nd
stage of labor

Second Stage (Stage of Expulsion)
8. Hand Maneuver
a. Ritgen’s maneuver

- pressing forward on the chin


of the fetal head while
pressing the other hand
downward on the fetal occiput
b. palpate for cord coil

c. Suction mouth and nose

d. Deliver the shoulder, wait for


d. Place the newborn on
the mother’s abdomen and
encourage parents to touch
newborn

626
Second Stage (Stage of Expulsion)
9. Cor d Clamping & Cutting

Milk the cord towards the baby


-cut the cord when it stops pulsating
PLACENTAL
STAGE
Third Stage (Placental Stage)

C . T hir d Sta ge

(Placental Sta ge)
birth of the baby – expulsion
of the placenta
normal blood loss: 300 – 500

ml
Third Stage (Placental Stage)
1.Placental Separation


a. Calkin’s sign
- uterus becomes globular in shape
Placental Separation


b. gushing of blood

- 2nd sign


Placental Separation


c. lengthening of the cord

- 3rd sign

Third Stage (Placental Stage)
 2. Placental Expulsion

a. Br andt – Andrews
Maneuver
- application of
traction on the cord
by moving the forcep
up, down, L, R
Third Stage (Placental
Stage)

b. Shultz

- shiny (fetal side)


c. Duncan

- dirty or rough side


(maternal side)

Third Stage (Placental Stage)

2. Inspect the placenta


3. Episior r aphy
Third Stage (Placental
Stage)
Mgt:
Medication

a.Oxytocin (Syntocinon)
- given IV after delivery of baby
 - check BP (if less than 90/60, DO
NOT GIVE)


b. Methyler gonovine Maleate

(Mether gine) -
 - given IM after delivery of the
placenta
 - check BP (if more than 140/90, DO
4TH STAGE

STAGE OF

PHYSICAL
RECOVERY
Fourth Stage (Stage of Physical Recovery)
1. Assess uterine

contractility
- uterus must be firm & well
contracted
- check for uterine involution
– produces uterine
contraction that leads to
CRAMPING (afterpains)
- - check for heavy bleeding –
Fourth Stage (Stage of Physical Recovery)
 ❖ 1 H after delivery:
 uterus @ the level of the
umbilicus
❖ 1 day after delivery:
 uterus 1 fingerbreath below
umbilicus (1cm)
❖ 2nd to 9th day :
 less than 1 finger breath a
day
❖ 10th day :
Fourth Stage (Stage of Physical Recovery)

 2. Assess for lochial


discharge


a. Lochia Rubra
➸ bloody (dark) red
➸ up to 3 days
Fourth Stage (Stage of Physical Recovery)

b. Lochia Serosa

➸ 4 to 6 days
➸ brownish

c. Lochia Alba

➸ 7 to 10 days
➸ whitish

Fourth Stage (Stage of Physical Recovery)
 3. Assess perineum for
bleeding
- 300 to 500cc – NSVD
- 500 to 1000cc – C/S
- 4. Assess for level of pains
“Afterpains”
 – abdominal pain
associated with uterine
contractions – indicates
Fourth Stage (Stage of Physical Recovery)

5. Encourage increase in

oral fluid intake (when not


contraindicated) –
related to dehydrating
effects of labor
6. Start Breastfeeding
Puerperium
Puerperium
- delivery – 6 weeks

 Mgt:
1. Breastcare
✔ wash only with
water
✔ air drying
✔ wear bra

MASTITIS

649
MASTITIS
Usually unilateral infection of
the breast
May occur as early as 7th
postpartal day
Caused by: STASIS of milk in
breasts or Organism causing
infection enters through
cracked and fissured nipples 650
MASTITIS
CAUSATIVE AGENT:

Staphylococcus aureus

651
ASSESSMENT
LOCALIZED PAIN
SWELLING
REDNESS
FEVER
SCANTY BREASTMILK

652
MANAGEMENT
Broad spectrum antibiotic – CLOXACILLIN
Continue breastfeeding
Allow the infant to suck on the unaffected
breast first to promote let down reflex
Lubricate nipples with expressed milk
Cold compress and supportive bra – PAIN
RELIEF
Warm Compress – EDEMA
If breast has localized abscess – STOP
BREASTFEEDING; pump BREASTMILK is
an alternative
Educational teaching – MASTITIS is not
associated with BREAST CANCER and 653
 A nurse is preparing a list of self care
instructions for a post partum client who was
diagnosed with mastitis. Which of the
following instructions will NOT be included on
the list?

a.Wear a supportive bra.


b.Maintain a fluid intake of atleast 3000 mL
c.Continue to breast feed if the breasts are not
too sore.
d.Avoid decompression of the breast by breast
feeding or breast pump.

654
Puerperium
 2. Resumption of sex
 - intercourse may be
resumed when perineal &
uterine wounds have healed (2-
4 weeks)

 3. Return of Menstruation
- for breastfeeding mother:
 within 4 months
- bottlefeeds: within 4-8 weeks
Psychosocial
Adaptation
Psychosocial Adaptation

1. Taking – in Phase
✔ h a p p e n s first 3 d a y s

✔ p a ssiv e d e p e n d e n ce

✔ tim e fo r re fle ctio n

✔ little in te re st in ta k in g ca re

o f h e r ch ild
✔ talking about childbirth

experience
Psychosocial Adaptation

2. Taking–hold Phase
✔ independence

✔ lasts about 10 days

✔ woman already shows interest

in taking care of her baby



3. Letting-go Phase
✔ redefining new role
Postpar tum Blues
Postpartum Blues

Onset 3-5 days after birth

Symptoms sadness, fears


Incidence 75% of all births
Etiology probable hormonal changes, life changes

Therapy support, empathy

Nursing Role offer compassion & understanding


Postpartal
Depression
Postpartal Depression

Onset 1 to 6 months after birth


Symptoms anxiety, feeling of loss,
sadness

Incidence 10% of all births


Etiology history of poor parent relationship,
hormonal response

Therapy counseling
Nursing Role refer for counseling
Postpar tal
Psychosis
Postpartal Psychosis
Onset: within 1st month after birth

Symptoms: delusions, hallucinations

Incidence: 2% of all births

Etiology: possible activation of previous mental illness,


hormonal changes

Therapy: psychotherapy, drug therapy

Nursing role: refer for counseling, safeguard mother from injury


to self or newborn
ANDREA YATES

665
1. A 24yr old client on the labor unit is being coached in the
Lamaze method by her husband. On assessment, the nurse
finds the client to be 5cm dilated and with contractions coming
every 2-3 minutes. The client asked for pain relief. What is the
nurse's best action?

Check BP and pulse and FHR in response to


contractions
Realize that it is too early to give medication
and encourage husband to continue with
Lamaze coaching.
Arrange for a sonogram to determine fetal
position
Perform a vaginal examination to determine
666
dilation.
2. The nurse is instructing a 21 year old primigravida. What is
the definitive sign indicating that true labor has begun?

A.Lightening
B.Passage of the mucus plug
C.Rupture of the amniotic membranes
D.Regular progressive uterine contractions that
increases in intensity with activity.

667
3. You are caring for a patient in the labor unit. You asked her
about the intensity of her contractions. She informed you that
her contractions are still quite a lot to bear but she manages to
ease the pain by walking around. Based from this verbalization,
you will note that:

A.True labor has begun.


B.Braxton Hicks contraction is present.
C.She needs to be taken to the D.R. as soon as
possible
D.There is a significant need for an I.E.

668
4. You are studying about the cardinal movements in childbirth.
You are aware of the fact, that when the baby has started
descent and it suddenly met an obstruction, the next cardinal
movement is:

A.Flexion
B.Extension
C.Engagement
D.Internal Rotation

669
5. The nurse is caring for a woman in labor. The woman is
irritable, complains of nausea and vomits and has heavier show.
The membranes rupture. The nurse understands that this
indicates:

A.Transition stage of labor


B.Latent stage of labor
C.Imminent delivery
D.Labor is slowing down and may need oxytocin

670
6. Appropriate nursing diagnosis for patients who are in
the latent stage of labor is:

A.Fluid Imbalance: Less than Body


requirements r/t NPO status
B.Impaired gas exchange r/t anesthesia
administration
C.Acute pain r/t labor
D.Impaired cognitive thinking r/t to labor pains

671
SITUATION : Katherine, a 32 year old primigravida at 39-40
weeks AOG was admitted to the labor room due to hypogastric
and lumbo-sacral pains. IE revealed a fully dilated, fully effaced
cervix. She is immediately transferred to the DR table. Which of
the following conditions signify that delivery is near?
I. A desire to defecate
II.Begins to bear down with uterine contraction
III.Perineum bulges
IV.Uterine contraction o ccur 2-3 minutes
intervals
A.I, II, III
B.I, II, III, IV
C.I, III, IV
D.II, III, IV 672
The nurse checks the perineum of a pregnant client. Which of
the following characteristics would cause an alarm to the nurse?
I. Greenish
II.Scanty
III.Blood tinged
IV.Clear

673
SITUATION : Pillar is admitted to the hospital with the following signs :
Contractions coming every 10 minutes, lasting 30 seconds and
causing little discomfort. Intact membranes without any bloody shows.
Stable vital signs. FHR = 130bpm. Examination reveals cervix is 3 cm
dilated with vertex presenting at minus 1 station.On the basis of the
data provided above, You can conclude the pillar is in the:
A.False labor
B.Active phase of labor
C.Latent stage of labor
D.Transitional phase of labor

674
Which of the following is characteristic of false labor?

A.Bloody show
B.Regular contractions that increase in
frequency and duration
C.Contraction are felt in the back and radiates
toward the abdomen
D.None of the above

675
Immediately following the birth of the baby, the nurse
should give what medication?

A.Heparin IV
B.Oxytocin IM
C.Methergine IM
D.Oxytocin IV

676
Mastitis is the infection of the breasts that may occur within one
week following delivery if the mother is breastfeeding. Ria, a
breastfeeding mother, complained that her left breast is swollen
and painful. She asked if it is okay to stop breastfeeding. The
nurse's best statement would be:
A.It’s okay to temporarily stop breastfeeding as long as
you continue to decompress the breast by means
of breast pump.
B.Unfortunately, cessation of breastfeeding can cause
stasis of breastmilk and can further aggravate
mastitis. You must continue breastfeeding.
C.No. the only two accepted reasons to stop
breastfeeding are abscess formation and intake
of antibiotics.
D.Let the child suck on the affected breast for the first
677
few minutes as vigorous sucking takes place
Complications of
Pregnancy
BLEEDING
DISORDERS

679
Bleeding Disorders
First Trimester
AB
O
RT
IO
N
Bleeding Disorders

I. ABORTION


A. Spontaneous Abor tion
 ☞ loss of a fetus before the
age of viability ( 20 weeks
or 500 gms)
Abortion
Classification

1. T hr eatened Abor tion
☞ vaginal bleeding or

spotting
(with no or slight

abdominal cramps)
☞ cervix is closed
Abortion
 Mgt:
 a. bedrest
 b. avoid coitus for 1-2
weeks
 following last
evidence of
 bleeding

Abortion


2. Inevitable / Imminent
Abor tion

 ☞ abortive process is
going on
☞ uterine contractions

occur
Abortion
 Mgt:

 a. save tissue fragments


for examination
 b. IV oxytocin is used to
expel
c. D &C to remove products

of conception
Abortion


3. Complete Abor tion
 ☞ entire products of
conception without any
assistance.
- Uterus contracts

effectively (LESS
Abortion

4. Incomplete Abor tion

☞ massive bleeding r/t
retained fragments
- Uterus does not contract

effectively
 Mgt:
☞ Dilatation & Curettage
(D&C)
Abortion

5. Missed Abor tion
- Fetal death befor e 20 wks of

pre gnancy
☞ intermittent bleeding
☞ no increase in fundal

height
☞ previously heard fetal

heart sounds cannot be


Abortion
Mgt:
a. Evacuation

b. Dilatation & Curettage

c. Psychosocial support –

emotional recovery
takes a year or more

Abortion
Abortion

6. Habitual or Recur r ent
☞ 3 spontaneous abortions

occurring successively
 Mgt:
a.depends on what type of
abortion
REMINDER:
HCG LEVEL IS STILL ELEVATED

LESS THAN 10 DAYS AFTER AN


ABORTION

EXCEPT: MISSED ABORTION


695
Abortion

B. Induced
Abor tion

 ☞ voluntary method
of terminating
pregnancy
Abortion
Purposes:
a. preserve health of the mother

b. prevent the birth of an infant

with severe defects


c. end pregnancy caused by rape or

incest
d. to terminate the pregnancy of

woman who chooses not to have a


child @ this time in her life –
MAJORITY OF REASONS
Abortion
Types:


1. Therapeutic
 - termination of
pregnancy done for the
purpose of safeguarding
the health of the mother
Abortion


2. Elective
 - interruption of
pregnancy @ the
request of the woman
but not for reasons of
impaired maternal
health or fetal distress
Abortion
Methods:
a. Vacuum aspiration or
curetta ge
☞ done up to 13 weeks of

gestation
☞ cramping is expected

20-30 mins after


RESULT
Abortion

b. Dilatation &
Evacuation
- done from 13 weeks to

16 weeks of gestation
- cervix is dilated with:

☞ Laminaria
☞ Prostaglandin Gel
RESULT
Abortion


c. Saline Induction
 - done on 16th week
up to 24thweek
gestation
Saline Method
A client 12 weeks’ pregnant come to the

emergency department with abdominal


cramping and moderate vaginal bleeding.
Speculum examination reveals 2 to 3 cms
cervical dilation. The nurse would
document these findings as which of the
following?
 A. Threatened abortion
 B. Imminent abortion
 C. Complete abortion
 D. Missed abortion

710
ECTOPIC

pregnancy
Ectopic Pregnancy
 Sites:
❖ cervix
❖ fallopian tube
❖ ovaries
❖ abdomen
Ectopic Pregnancy
 Causes:
 - narrowing of the
tube
- pelvic infection
- endometriosis
- Smoking
Ectopic Pregnancy
 Manifestations:
1.vaginal bleeding (6-
12wks)
2.knife-like abdominal pain
3.referred pain on the
shoulder
4.symptoms of shock
5.pelvic pressure or
fullness
6.pelvic mass
Ectopic Pregnancy
Diagnosis:

1.Culdocentesis
2.UTZ
3.Hysterosalpingogram
Ectopic Pregnancy
 Mgt:
1. monitor amount of
bleeding
2. monitor V/S
3. assess/ observe for
abdominal pain
4. blood transfusion
5. prepare for surgery
Ectopic Pregnancy
 ✔ Salpingostomy
✔ Salpingectomy
✔ Oophorectomy
 6. psychological/
emotional
 care
Ectopic Pregnancy
 ✔ Drug of choice:
METHOTREXATE +

LEUCOVORIN
- attacks & destroys fast

growing cells
Mifepristone –

abortifacient ; causes
sloughing off of tubal
Bleeding Disorders

Second Trimester
HYDATIDIFORM

mole
Hydatidiform Mole

( H mole )

☞ also called
Gestational
Trophoblastic Neoplasm

 ☞ characterized by
proliferation of chorionic
villi into mass of clear
vesicles
Hydatidiform Mole
 Predisposing Factors:
 a. low socio economic
status
b. women below 18 or
above 35
 years old
c. women of Asian heritage

Hydatidiform Mole

Types:

1.Complete / Classic
2.Incomplete / Partial
Hydatidiform Mole
 Manifestations:
a. vaginal bleeding
b. excessive nausea & vomiting
c. rapid enlargement of uterus
d. (+) pregnancy test
e. abdominal cramps
f. absent FHR
g. elevated HCG titer: 1-2m IU
(N:400,000 IU)

Hydatidiform Mole
Diagnosis:
1. HCG titer
2. UTZ
3. X-Ray
Mgt:

a. D&C; suction curettage


b. Chemotherapy: Methotrexate
 – drug of choice (only if high
levels of HCG is persistently rising)
c. Monitor HCG level x 1yr
d. Delay childbearing for 1 year
e. Perineal pad count
f. Chest X-ray (once a month x
1yr)
INCOMPETENT

cervix
Incompetent Cervix
Causes:

a. congenital anomaly
b. trauma
Risks:

a. Habitual abortion
b. Preterm labor
733

Incompetent Cervix
 Manifestations:

- vaginal bleeding/show
- painless dilatation

- premature rupture of

membranes
Incompetent Cervix
Mgt:
a. bed rest

b. medications: Tocolytics



Ritodrine HCl

(Yutopar)

✔ Terbutaline SO4
(Brethrine)
 Side effects:

tachycardia, chest pain,


palpitations


Incompetent Cervix
 Cervical Cerclage
a. Shirodkar-Bartor
 - stitch through suture

 - suture is permanent

b. Mc Donald’s

 - purse-string suture
Bleeding Disorders

Third Trimester
Placenta Previa
Placenta Previa
 Predisposing Factors:
1. multiparity
2. advanced maternal age

3. alteration in uterine

structure
t ypes
A nurse is performing an assessment on a client
diagnosed with placenta previa. Which of these
assessment would the nurse expect to note?

a.Uterine rigidity
b.Uterine tenderness
c.Severe abdominal pain
d.Soft, relaxed, non-tender uterus
Placenta Previa

Manifestations:
- painless bleeding
- heavy bright red
bleeding
- soft, non tender uterus
FETUS – no decrease in

fetal movement
Placenta Previa
 Nursing Intervention:
1. bed rest in L side lying
position
2. Tocolysis
3. no IE/ enema
4. O2 by face mask
5. perineal pad count
6. assess for symptoms of shock
7. monitor FHB
8.psychological support
Abruptio Placenta
Abruptio Placenta
 Predisposing Factors:
1. chronic hypertensive
disease
2. multigravida
3. history of short cord
4. trauma
5. inhalation of cocaine
Abruptio Placenta

 Types:
1. Covert or Central
2. Partial or Marginal
3. Complete or Total
Abruptio Placenta
Manifestations:

- painful, dark brown bleeding


 - variable amount of bleeding
 - severe low abdominal
cramping
 - low back pain
- rigid, board like uterus
- with abdominal tenderness
FETUS - Decrease in fetal mov’t
Abruptio Placenta

 Complications:

1. Couvelaire Uterus
2. Shock
3. DIC

Abruptio Placenta
Interventions:

1. bedrest in side lying


position
2. Tocolysis
3. IVF
4. adm O2 as ordered
5. perineal pad count
6. assess s/s of shock
7. monitor fetal status
8. psychological support
MEMORY AID : ABRUPTIO

 PLACENTA PREVIA PLACENTA

Manifestations: Manifestations:
- painless - painful
- bright red  - dark brown
bleeding bleeding
- soft uterus - rigid, board like
 - non tender uterus
uterus - abdominal
 FETUS – no tenderness
decrease in fetal - abdominal
movement cramping
756
  - low back pain
Elise is on her 22nd week of gestation when the
doctor told her that fetal heart sounds are no
longer audible. UTZ and laboratory results show
that her baby is already dead. As a nurse, you
know that the specific term for this type of
abortion is:

A.Missed abortion
B.Fetal demise
C.Habitual abortion
D.Threatened abortion

757
Marsha who is 8 weeks pregnant reported
vaginal spotting. Upon further assessment, the
patient verbalized uterine cramping and you
noted 2cm dilatation. This type of abortion is
known as:

A.Threatened Abortion
B.Imminent Abortion
C.Incomplete abortion
D.Complete abortion

758
Your patient was diagnosed with H-mole and
recovered through chemotherapy. She asked
you why she must avoid pregnancy for 1 year.
The nurse’s best statement is:
A.Pregnancy can cause elevation of the HCG level
therefore predisposing your patient to a
possibility of another H-mole formation.
B.Pregnancy can cause elevation of the HCG
which can mislead the physician thinking that
remission or metastasis has occurred.
C.Pregnancy can hinder the success of
chemotherapy.
D.Pregnancy can cause stress to the patient and
this can cause H-mole formation. 759
A full term pregnant woman is admitted to the
facility with a diagnosis of abruptio placenta.
Which assessment finding isn’t related to
abruptio placenta?
A.Tender, boardlike uterus
B.Signs of shock
C.Hypertension
D.Painful vaginal bleeding

760
A 31 yr old client is admitted to the nursing unit
with the diagnosis of placenta previa. Which
sign or symptom isn’t seen with placenta
previa?
A.Bright red painless vaginal bleeding
B.Implantation of the placenta in the lower
uterine segment
C.No decrease in fetal movement
D.Severe pelvic pain

761
Ariana, your patient diagnosed with incompetent
cervix is with cervical cerclage. The best time to
remove the suture is:

A.When the cervix has completely dilated


B.When the bag of water has ruptured
C.Upon the onset of true labor
D.During the active stage of labor

762
Other complications
of pregnancy
Premature
Rupture
of Membranes
Premature Rupture of Membranes
 Contributing Factors:
a. infection of the
vagina/membranes
(chorioamnionitis)
b. incompetent cervix
c. hydramnios
d. amniotic sac with weak
structure
e. recent sexual intercourse
When PROM occurs, which of the
following provides evidence of the
nurse’s understanding of the client’s
immediate needs?
a. The chorion and amnion rupture 4 hours
before the onset of labor.
b. PROM removes the fetus most effective
defense against infection
c. Nursing care is based on fetal viability
and gestational age.
d. PROM is associated with
malpresentation and possibly incompetent
cervix 767
INTERVENTIONS
ASSESS FETAL HEART RATE
CHECK VAGINALLY FOR
PROLAPSED CORD
CHECK THE COLOR OF THE
AMNIOTIC FLUID
NORMAL : VERY LIGHT
YELLOW
BROWNISH GREEN :
MECONIUM STAINED 768
Premature Rupture of Membranes
Complications:

a. Infection
- increase after 24 hours
- risk for postpartum infection
for mother
- risk for neonatal sepsis
b. RDS
- occurs if preterm birth occurs
c. Cord Prolapse
Premature Rupture of Membranes
 Dx:
a. Nitrazine Test
- to determine pH
 - alkaline > 6.5 – 7.25
change from blue greento
dark blue

Premature Rupture of Membranes
Mgt:

a. Gestation Near Term

- induction of labor
- CS may be done
Premature Rupture of Membranes
b. Preterm gestation
- cervix is usually not
 favorable for induction
 - Corticosteroid Therapy
Betamethasone – hasten lung

maturity
- Antibiotics – prevent infection;

Penicillin

- CS may be done
Premature Rupture of Membranes
 Nsg. Intervention:
a.check FHR
b.check vaginally for prolapsed
umbilical cord, or in case of
advance labor for descent of
presenting part
c.check the color of amniotic fluid
 Normal: clear
Meconium Stained:
 Breech - normal
  Cephalic – fetal distress
Premature Labor
and Birth
Which of the following best describes
preterm labor?

a. Labor that begins after 20 weeks
gestation and before 37 weeks gestation
b. Labor that begins after 15 weeks
gestation and before 37 weeks gestation
c. Labor that begins after 24 weeks
gestation and before 28 weeks gestation
d. Labor that begins after 28 weeks
gestation and before 40 weeks gestation

775
Premature Labor and Birth

Contributing Factors:
a. multiple gestation

b. Polyhydramnios

c. premature rupture of

membranes
d. incompetent cervix

e. placenta previa / abruptio

placenta
f. previous preterm labor
Premature Labor and Birth
 Triad Signs and
Symptoms:

1. Premature contractions every 10 mins


2. Effacement of 60 – 80 %

3. Dilation of 2-3 cm

PRIMIGRAVIDA – effacement first before


dilatation
MULTIGRAVIDA – effacement and

dilatation occurs spontaneously


Premature Labor and Birth
 Mgt:
a. Prevention of Premature
Delivery
 - bedrest
- monitoring of contractions
- IE
- Tocolytic drugs
 - Betamethasone (Celestone)
to hasten lung maturity –
optimal benefits begin 24 hours
after initial therapy.

Premature Labor and Birth
 b. Patient Teaching
- teach woman symptoms of
preterm labor

 • uterine contractions in regular pattern


for more than 1 hour while @ rest
• intermittent or constant uterine cramps
• low, dull backache
• intestinal cramping
• rupture of membrane
Premature Labor and Birth
COMPLICATION:

Respiratory Distress Syndrome – due


to lack of functional alveoli and
insufficient calcification of the bony
thorax

Mgt: (for babies with RDS)
Increase caloric intake
Keep infant in a high humidity environment
– liquify secretions making gas exchange
possible
MULTIPLE
GESTATION
782
 Multiple
Types:
Gestation
a. Mono zygotic Twins

b.


“ identical twins”
DIZYGOT
IC
TWINS
DIZYGOTIC
Multiple Gestation
 Manifestations:
a.uterine size is
greater than
expected

 b. palpation of three
or more large parts

 c. different FHT of
different
frequencies

 VANISHING TWIN
SYNDROME
790
Multiple Gestation
 Complications:
a. premature delivery
b. Hemorrhage

c. HPN

d. Fetal malpresentation

e. Uterine dysfunction due to

overstretching
f. Cord compression

g. Twin-to-twin transfusion syndrome


Multiple Gestation


Recipient Twin
- larger
- polycythemia

Donor twin
- SGA
- Anemia
797
Multiple Gestation
 Mgt:
a. Prenatal Care
b. Balanced diet
c. Rest periods
d. Anticipatory guidance
& support
Multiple Gestation
Delivery:
Caesarian Section

 Double Set Up – if the


other twin is in vertex
presentation, he may be
delivered VAGINALLY.
Rh

Inco
RH INCOMPATIBILITY
Rhesus D

Father – determines the Rh of
babies

Blood typing – determines Rh

801
Rh Incompatibility
 Rh (-) mom
 Rh (+) baby


1st Pregnancy
Prevention: Rhogam within 24
hours after delivery


2nd Pregnancy:
 ERYTHROBLASTOSIS FETALIS
Rh Incompatibility
Preventive Mgt:

a. Blood typing / Rh determination


b. Coomb’s test

 - Indirect – mother’s blood


 (check for anti Rh antibody
titer)
 - Direct – umbilical cord sample
 (check for the presence of
antibodies attached to RBC)
complications of
Labor & Delivery
Umbilical Cord Prolapse
Umbilical Cord Prolapse
 Causes:
1. breech

presentation
2. transverse lie

3. unengaged
 presenting
part
4. hydramnios
Umbilical Cord Prolapse
 S/S:
1. cord is protruding from
vagina
2. cord can be palpated in
the vagina or cervix
3. fetal distress

Which of the following is the nurse’s
initial action when umbilical cord
prolapse occurs?

a. Begin monitoring maternal vital signs


and FHR
b. Place the client in a knee-chest position
in bed
c. Notify the physician and prepare the
client for delivery
d. Apply a sterile warm saline dressing to
the exposed cord
 811
Umbilical Cord Prolapse
Mgt:

1. knee chest
2. 02 – prevent fetal
hypoxia
3. push presenting part
upward
4. apply moistened sterile
towel
5. delivery ASAP

813
caesarian deliver y
Caesarian Delivery
 Indications:

Scheduled
 1. CPD
2. malposition
3. malpresentation
4. previous CS

 Emergency
5. complete or partial placenta previa
6. abruptio placenta
7. prolapsed umbilical cord
8. fetal distress
Caesarian Delivery
Types:

1 . Low segment /
Transverse incision /
Pfannensteil
- incision done across the abdomen just over
the symphysis pubis
- blood loss is minimal
- possibility of later rupture is lessened
 - takes longer to perform
2 . Classic CS /
Vertical incision
- incision is made vertically through both the
abdominal skin & uterus
- done for anterior placenta previa
- done for transverse lie fetus
Caesarian Delivery
Nursing Care:

1.monitor V/S closely


2.check dressing site
3.inspect perineal pad
4.check fundus for firmness
5.breathing exercises
6.out of bed 1st post op day
7.Encourage patient
st
to get up
and walk 1 post op day to
decrease the risk of blood
clots
8.have the woman hold the baby
ASAP
Hypertensive
Disorder
of
Pregnancy
A home care nurse is monitoring a pregnant

client with gestational hypertension who is at


risk for preeclampsia. At each home care visit,
the nurse assesses the client for which classic
signs of preeclampsia? .

a.Proteinuria
b.Hypertension
c.Generalized edema
d.All of the above

 Hypertensive Disorder of

Pregnancy


PIH

 - a syndrome of HPN, edema & proteinuria


appearing after the 20th week of pregnancy
PIH
Vasospasm occurs during
pregnancy
Caused by the action of
prostaglandins and
responsiveness to
ANGIOTENSIN

825
Hypertensive Disorder of Pregnancy
 Risk Factors:
a. primi younger than 20
b. primi older than 40
c. low socio economic
status
d. hydramnios
e. underlying diseases
Hypertensive Disorder of Pregnancy
 Manifestations:

1.Mild Pre-Eclampsia
- increase systole 30 mmHg
- increase diastole 15 mm
Hg taken on 2 occasions at
least 6 hrs apart
- mild edema of hands &
feet
- weight gain of 1.5 lbs –
2lbs/week
- proteinuria 1+ or 2+
Hypertensive Disorder of Pregnancy
2. Sever e Pr e-Eclampsia


- increase to 160/110 mmHg
 - proteinuria 3+ - 4+
- oliguria (500 ml in 24 hours)
- headache
- blurring of vision
- generalized edema
Hypertensive Disorder of
Pregnancy

3. Eclampsia


- presence of convulsions
r/t cerebral edema

- Coma

- hypertensive crisis or
shock
Hypertensive Disorder of Pregnancy
Management:
Mild/Severe Pre-Eclampsia

- Bed rest in side lying position


- quiet & calm environment


- Provide a darkened room
- monitor fetal/maternal well

being
Hypertensive Disorder of Pregnancy
- High protein diet; limit SALT
- administer meds

 ❖ Hydralazine (Apresoline)
* antihypertensive
 ❖ MgSO4 (drug of choice) -
IV
* prevents seizures
* reduces edema (cathartic
action: promotes fluid shifting)
Hypertensive Disorder of
Pregnancy

MgSO4 Toxicity
* Urine output less than 100 ml in 4 hours
* RR less than 12-14 cycles

* Patellar reflex - absent

* Signs of fetal distress

* Serum Mg level greater than 2.5 mEq/L


ANTIDOTE:
CALCIUM GLUCONATE - IV
Hypertensive Disorder of
Pregnancy
2. Eclampsia

a.adm O2
b.Bed rest
c.side lying to drain secretions
d.external fetal monitor
e.Private room, darkened and quiet
f.MgSO4 or diazepam
g.termination of pregnancy
Other
Complications
of Pregnancy
Gestational

Diabetes
Gestational Diabetes
Cause:

 glucose intolerance

due to:
♣ inadequate
response of insulin to
CHO
♣ insulin resistance
Gestational Diabetes
Risk Factors:

a. family history of
diabetes
b. obesity
c. previous macrosomic
baby
Gestational Diabetes
SCREENING AND ASSESSMENT


GLUCOSE SCREENING TEST – no fasting

- oral 50-g glucose load
- Venous sample is then taken after 1 hour
- If glucose is more than 140mg/dL

-
- GLUCOSE TOLERANCE TEST – with 3
hours fasting
- 100-g glucose load
- 2/4 blood sample showed >130mg/dL

-
Gestational Diabetes

GDM Mothers usually have


MACROSOMIC babies
-Mothers prone to vaginal

lacerations

Macrosomic babies are likely to


experience BIRTH INJURIES


(shoulder dystocia)
840
841
Gestational Diabetes
Effects of DM on baby @ birth:


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

N: blood glucose: 45- 55 mg/dL



Gestational Diabetes
Insulin administration

1.Rapid acting insulin (Regular


Insulin)
2.Intermediate acting (NPH)
- Give BID
- AM – 30mins before breakfast
- PM – just before dinner
2. Blood Glucose Monitoring

845
1. The first sign of placental separation is:
A.When the uterus becomes spherical in shape
B.Lengthening of the cord
C.Shortening of the cord
D.Gushing of blood

846
2. The nurse is caring for a client who is receiving
Pitocin to induce labor. While administering the
oxytocin, it's most important to monitor the:

A.Fetal heart rate


B.Urine output
C.Maternal blood glucose
D.Central venous pressure

847
A primigravida who is 30wks pregnant is admitted to
the labor unit. She started on ritodrine HCl to arrest
her labor. The nurse should observe the client for
adverse reactions to this drug which include:
A.Chestpain
B.Bradycardia
C.Hyperglycemia
D.Diplopia

848
A client who is in her 13th week of gestation has
been instructed to call the clinic if danger signs
occurs. Which statement indicates she knows what
to report?
A.I’ll call the clinic if I have blurring of vision
B.I’ll call the clinic if I have shortness of
breath when I walk up the steps
C.I’ll call the clinic if I notice my feet swelling
D.I’ll call the clinic if I have sudden burst of
energy.

849
In the DR, the nurse positions client for insertion of
indwelling catheter and notices a glistening white
umbilical cord protruding from the cliet's vagina.
What should be the nurse's first action?
A.Return to the nurse’s station and call the
physician
B.Start oxygen by face mask
C.Place a clean towel over the umbilical cord,
then wet the cord with sterile saline
solution
D.Apply manual pressure to the presenting
part and place the client in knee chest
position 850
Danah ruptured her bag of water and she is only on
her 34th week of pregnancy. Upon assessment, the
L:S ratio is only 1:1. The best action by the
healthcare team is to first:
A.Give Betamethasone IM to increase the
number of lung surfactants
B.Prepare for delivery asap
C.Prevent infection by giving antibiotics
D.Encourage the patient to ambulate to speed
the stages of labor

851
Your patient who is diagnosed with gestational
diabetes mellitus and delivered through NSVD is
prone to:
A.PIH
B.Vaginal lacerations
C.Cardiac defects
D.Shoulder dystocia

852
Your patient who delivered 4 hours ago has already
soaked 2 maternal pads in just 1 hour. Because of
the dehydrating effects of bleeding, she asked for a
glass of water. Your action will be based on which
of the following:
A.The patient must be placed on NPO
B.Give the glass of water and increase the rate
of IVF to prevent dehydration
C.Telling her that she can have her favorite
meal to increase her caloric intake
D.Document the findings and report to the
physician, then give her the glass of
water. 853
E.
Thank you… 855
CARDIAC

disease
Cardiac Disease
Classifications:
Class I Asymptomatic with all activity

Class II Asymptomatic @ rest; symptomatic with heavy


physical activity

Class III Asymptomatic @ rest,


symptomatic with ordinary activity

Class IV Symptomatic with all activity, symptomatic with


rest
Cardiac Disease
 Effects on the Fetus:
a. retarded growth
b. fetal distress
c. premature labor

 Mgt:
Goal: to reduce wor kload of
the hear t
Cardiac Disease

1.Promote rest
2.Promote a healthy diet
- increase iron to prevent
anemia
3.Educate regarding meds
a. Digitalis may be given to
increase contractility of the
heart
b. Penicillin may be given to
Cardiac Disease
4. Educate regarding avoidance of infection
5. Promote reduction of psychologic stress

6. Deliver

 Class I & II :
 good prognosis for vaginal
delivery
 Class III & IV :
 poor prognosis for vaginal
delivery

 ❖ no to lithotomy position and valsalva


 manuever
❖ high fowler’s position
Question
A nurse is conducting a clinic visit with

prenatal client with heart disease. The


nurse carefully assesses the client’s
vital signs, weight, and fluid and
nutritional status to detect
complications caused by:

a. hypertrophy and increased


contractility of the heart
b. the increase in circulating blood

volume
c. fetal cardiomegaly


STDs
candidiasis
Sexually Transmitted Disease
 Causative Agent:
 CANDIDA ALBICANS
 S/Sx
✔ cream cheese like vaginal discharge
✔ dyspareunia

✔ itchiness and reddening of the vulva


866
Sexually Transmitted Disease

 Management:

✓ 1% gentian violet
✓ nystatin

suppository

Sexually Transmitted Disease

 Fetal Effect:

 Thrush or Oral
Candidiasis

871
Trichomoniasis
Sexually Transmitted
Disease
Causative Agent:
 TRICHOMONAS VAGINALIS

S/Sx

✓ FROTY-WHITE to greyish

vaginal discharge
✓ pinpoint petechiae on the

vagina
Sexually Transmitted
Disease
 Management:

 ✓ Metronidazole (Flagyl)
(given to a non pregnant

women)
✓ Vaginal douching

 Dilute vinegar solution or

betadine
✓ Clotrimazole (canesten)
clamydia
Sexually Transmitted
Disease
Causative Agent:
 CLAMYDIA TRACHOMATIS

S/Sx

 ✓ heavy, gray white vaginal


discharge
✓ dyspareunia
✓ dysuria

✓ friable cervix
Sexually Transmitted
Disease
 Management:
✓ erythromycin
✓ ampicillin

 Fetal effects:
✓ trachomonal inclusion conjunctivitis
✓ pneumonia
gonor rhea
Sexually Transmitted
Disease
Causative Agent:

 Neisseria Gonorrhea

S/Sx

(F)- Asymptomatic

(M) - Burning on urination

 - urinary frequency
 - purulent penile
discharge
884
Sexually Transmitted
Disease
Management:

- erythromycin

- penicillin G

Fetal effects:
- Opthalmia Neonaturum

 may cause blindness

 Crede’s Prophylaxis

given
syphilis
Sexually Transmitted
Disease
Causative Agent:

 Treponema Pallidum

S/Sx

 chancre
 - painless characteristic
lesion that may appear on
the mouth, genital area,
rectal area
889
Sexually Transmitted
Disease
Management:
✓ erythromycin

✓ benzanthine

penicillin
Sexually Transmitted
Disease
Fetal Effects:
 a. abortion
 b. still birth
 c. congenital syphilis
 hutchinson’s teeth (narrowed incisor
teeth)
 saddle nose
 blisters and peeling skin
 fissures around hips and anus
Hutchinson’s teeth
Saddle nose
Blisters and peeling of skin
Blisters and peeling of skin
TORCH
infections
toxoplasmosis
TORCH Infections
Causative Agent:
 Toxoplasma Gondii

MOT

✓ eating undercooked meat


✓ contact with cat stool or

litter (birds,cattle)
TORCH Infections

s/sx
✓ Almost no symptoms

✓ Cervical

lymphadenopathy
✓ Malaise for few days
TORCH Infections
Fetal effects

✓ spontaneous abortion
✓ cns damage

Treatment: sulfadiazine

r ubella

German Measles
TORCH Infections
Causative Agent:



viral

MOT
✓ droplet infection
TORCH Infections
s/sx
✓ Fever

✓ Rash

✓ lymphedema
TORCH Infections
 Fetal effects
- deafness

- mental and motor

retardation
- cataracts

- cardiac defects

- facial clefts
A 1 day post partum clients rubella titer result is
lower than 1:8 & a rubella virus vaccine is
prescribed to be administered before
discharge. The nurse provides which
information to the client about the vaccine?
Select all that apply.
a.Pregnancy needs to be avoided for 1 to 3
months.
b.The vaccine is administered by the
subcutaneous route.
c.A hypersensitivity reaction can occur if the
client has an allergy to eggs.
d.All of the above
cytome gal y
TORCH Infections
Causative Agent:

 Cytomegalovirus

(CMV)

MOT
✓ droplet infection
TORCH Infections
 s/sx: asymptomtic

Fetal effects
✓ brain damage

✓ eye damage

✓ chronic liver disease


her pes simplex II
TORCH Infections
Causative Agent:

 Herpes virus hominis

type 2 (HVit.2)

MOT
✓ sexually transmitted
TORCH Infections

 s/sx
✓ Painful pinpoint
vesicles
✓ Fever

✓ Malaise

✓ Dyspareunia


916
TORCH Infections
Fetal effects

- spontaneous abortion

- vesicles covering the skin

- dyspnea

- fever

- lethargy

 Tx: Acyclovir (Zovirax)- unsafe for pregnant


A nurse is providing instructions to a pregnant
client with genital herpes about the measures
that are needed to protect the fetus. The nurse
tells the client that :

a. Total abstinence from sexual intercourse is


necessary during the entire pregnancy
b. A cesarean section will be necessary if vaginal
lesions are present at the time of labor
c. Sitz bath need to be taken every 4 hours while
awake if vaginal lesions are present
Daily administration of acyclovir (Zovirax) is
necessary during the entire pregnancy

918