Maternity Nursing

I. Basic Knowledge on Genetics and Obstetrics 1. 2. 3. 4. 5. 6. DNA Deoxyribonucleic Acid carries genetic code Chromosomes threadlike structure of hereditary material known as the DNA Normal amount of ejaculated sperm 3 5 cc/ 1 teaspoon Ovum is capable of being fertilized within 24 36 hours after ovulation. Sperm 48 72 days viability Reproductive cells divide by the process of MEIOSIS (haploid number) Spermatogenesis process of maturation of sperm Oogenesis process of maturation of ovum o 30 weeks AOG 6 million immature ovum o @ birth 1 million immature oocytes o @ puberty 300 400 immature oocytes o @ 13 y/o 300 400 mature oocytes o @ 23 y/o 180 280 mature ovum o @ 33 y/o 60 160 mature ovum o @ 36 y/o 24 124 mature ovum o @46 y/o 4 mature ovum Gametogenesis process of formation of two haploid into diploid 7. Age of reproductivity 15 44 y/o childbearing age 20 35 y/o High risk <18 & >35 y.o. With Risk 18 20; 30 35 8. Menstruation Menstrual Cycle beginning of menstruation to the beginning of the next menstruation Average menstrual cycle 28 days Average menstrual period 5 days Normal blood loss 50 cc/ cup accompanied by FIBRINOLYSIS prevents clot formation Related terminologies o Menarche 1st menstruation o Dysmenorrhea painful menstruation o Metrorrhagia bleeding in between menstruation o Menorrhagia Excessive bleeding during menstruation o Amenorrhea absence of menstruation o Menopause cessation of menstruation (Average Age- 51 y.o.) Tofu has isoflavone estrogen of plant that mimics the estrogen with a woman 9. Functions of Estrogen and Progestin ESTROGEN hormone of woman o Primary function Responsible for the development of secondary characteristics in females inhibit production of FSH o Other function Hypertrophy of the myometrium Spinnbarkeit and Ferning Pattern (Billings Method) Ductile structure of the breast Osteoblastic bone activity (causes increased in height) Early closure of the epiphysis of the bone Sodium retention

Increased sexual desire Responsible for vaginal lubrication PROGESTERONE Hormone of the mother o Primary function prepares the endometrium for implantation making it thick and tortous o Secondary Function inhibit uterine contractibility o Others Inhibit LH (hormone of ovulation) production GI motility Permeability of kidneys to lactose and dextrose causing + 1 sugar in urine Mammary gland development BBT Mood swings

10. Menstrual Cycle 4 phases of menstrual cycle 1. Proliferative 2. Secretory 3. Ischemic 4. Menses 1. On the initial phase of menstruation, the estrogen level is , this level stimulates the hypothalamus to release GnRH/ FSHRF 2. GnRH/ FSHRF stimulates the anterior pituitary gland to release FSH FSH Function o Stimulate ovaries to release estrogen o Facilitate the growth of primary follicle to become GRAAFIAN FOLLICE structure that secretes large amount of estrogen that contain mature ovum 3. Proliferative Phase (estrogen) Follicular Phase responsible for the variation and irregularity of mense Postmenstrual Period after menstruation Preovulatory Phase happen before menstruation 4. 13th day of menstruation, estrogen level is PEAK while progesterone is , these stimulates the hypothalamus to release GnRH/ LHRF 5. GnRH/ LHRF stimulates the Anterior Pituitary Gland to release LH Functions of LH o Stimulates the release of progesterone o Hormone for ovulation th 6. 14 day estrogen level is while progesterone level is S/S o Rupture of the graafian follicle - OVULATION o Mittelschsmerz slight abdominal pain lower right quadrant 7. 15th day, after ovulation day, graafian follicle starts to degenerate, estrogen level , progesterone , causing degeneration of the graafian follicle becoming yellowinsh known as CORPUS LUTEUM secretes large amount of progesterone 8. Secretory Phase Lutheal Phase ( progesterone) Postovulatory phase

Premenstrual Phase 9. 24th day Corpus Albicans (whitish) corpus luteum degenerates and becomes white 10. 28th day if no sperm united the ovum, the uterine begins to slough off to have the next menstruation Note: if there is no fertilization, corpus luteum continues functioning Ovarian Cycle from primary follicle corpus albicans Stages: o 1 5 days menses o 6 14 proliferative o 15 26 secretory o 27 28 ischemic II. Wonders of Fertilization a. Fertilization 1. Phonones song of sperm 2. Capacitation ability of sperm to release proteolytic enzyme and penetrate the ovum b. Stages of Fetal Growth and Development 1. Pre Embryonic Stage Zygote fertilized ovum (3 4 days travel, 4 days floating)> from fertilization Morula mulberry-liked ball containing 16 50 cells Blastocyst enlarging cell forming a cavity that later becomes the embryo covered by thropoblast which later becomes the placenta and membrane Implantation 7 10 days after fertilization Thropoblast covering of blastocyst that become placenta S/Sx of Implantation Slight pain, Slight Vaginal Spotting 3 Processes o Apposition o Adhesion o Invasion 2. Embryonic Stage Zygote fertilization to 14 days Embryo 15th 2 mos/ 8 weeks Fetus 2 mos to birth c. Decidua thickened endometrium, latin word for falling off 1. Basalis located directly under the fetus where placenta developed 2. Caspularis encapsulates the fetus 3. Vera remaining portion of and endometrium d. Chorionic Villi 10 11 weeks 1. Chorionic Villi Sampling (CVS) removal of tissue from the fetal postion of the developing placenta For genetic screening Fetal limb defects, missing digits of toes e. Cytothrophoblast outer layer, LANGHANS LAYER, protect the fetus against syphilis (24 weeks/ 6 months) f. Synsitiotrophoblast syncitial layer responsible for hormone production 1. Amnion inner most layer 2. Chorion Umbilical cord (Funis) whitish gray (50 60 cm) Short abruptio placenta, uterine inversion Long cord prolapse, cord coil 3 vessels (AVA) Artery Vein Artery

I. II. III. IV.

I.

II.

Whartons Jelly protects the umbilical cord Amniotic fluid bag of water clear color, musty/mousy odor With crystallized forming pattern, slightly alkaline 500- 1000 cc Normal o Oligohydramnios kidney malformation o Hydramnios GIT , TEF/ TEA Functions o Cushion the fetus against sudden blow or trauma o Maintains temperature o Facilitate muscuskeletal development o Prevents cord compression o Helps in development process

Diagnostic Test for Amniotic Fluid Amniocentesis Purpose: obtain sample of amniotic fluid by inserting a needle hrough the abdomen into the amniotic sac Fluid is tested for: Genetic screening Determination of fetal maturity primarily by evaluating factors indicative of lung maturity Done with empty bladder Complication > Most common side effect : INFECTION > Late : pre term labor > Early : spontaneous abortion Indication for Amniocentesis: > Early in Pregnancy Advance Maternal Age > Later in Pregnancy Diabetic Mothers - down syndrome - neural tube defect, spina befida L/S ratio : 2:1 (Lecitin/ Spingomyelin) Definitive test = Phosphatiglycerol: PG + best Answer Greenish Meconium Stains (Fetal Distress) Yellowish jaundice, hyperbilirubinemia Cloudy Infection Most Important Consideration Needle insertion site Amnioscopy direct examination through intact fetal membrane via ultrasound Fern Test a test determining if bag of water has rupture or not Nitrazine Paper Test differentiate amniotic fluid and urine Blue geen + rupture of bag of H2O 2. Chorion outermost layer a. Placenta AKA Secundines chorionic Villi and basalis Pancake in latin 500 grams in weight 15 28 cotyledons 15 20 cm in diameter and 2 3 cm in depth Functions o Respiratory 02 CO2 exchange via simple diffusion o GIT glucose transport via facilitated diffusion

o o o

Excretory via 2 arteries, carries unoxygenated blood then detoxify by maternal liver Circulatory fetoplacental circulation by SELECTIVE OSMOSIS Endocrine HCG primary maintain corpus luteum/ secondary basis of pregnancy test Human Placental Lactogen aka Somatomammothrophin Responsible for the development of mammary gland Diabetogenic Effect insulin antagonist Relaxin softening of maternal joints and bones Serves as protective barrier against some microorganism Can pass: HIV CMV Rubella PINOCYTOSIS transport of virus

Pregnancy 266 288 days/ 37 42 weeks FETAL STAGE: Fetal Growth and Development First Trimester : Period of organogenesis, most critical period First Month FHT, CNS Develops, GIT and Respi Tract remains as single tube Differentiation of Primary Germ Layer Endoderm o Thyroid responsible for basal metabolism o Thymus immunity o Liver o GIT o Linings of Upper GI Tract Mesoderm o Heart o Musculoskeletal o Reproductive Organ o Kidney Ectoderm o Brain o CNS o Skin o 5 senses o Hair, nails o Anus o Mouth Second Month Life span of corpus luteum ends All vital organs are formed Placenta is developed Sex organ is developed Meconium is present Third Month

 Placenta is complete Kidneys are functional Fetus begins to swallow amniotic fluid Buds of milk appear Sex is distinguishable FHT audible via dopples @ 10 12 weeks Terratogens any drug or irradiation, the exposure to which may cause damage to the fetus DRUGS o Streptomycin anti TB (quinine) damage to the 8th cranial nerve poor learning and deafness/ ototoxic o Tetracycline stoning the tooth enamel, inhibits long bone growth o Vitamin K hemolysis, destruction of RBC, jaundice, hyperbilirubenemia o Iodides enlargement of thyroid and goiter o Thalidomides anti-emetics Amelia or Pocomelia absence of distal part of extremities o Steroids cleft lip or palate and even abortion o Lithium congenital maformation ALCOHOL LBW, fetal alcohol syndrome ( characterized by microcephaly) SMOKING LBW CAFFEINE LBW COCCAINE LBW, abruptio placenta TORCH group of infections that can cross the placenta or ascend through the birth canal and adversely effect fetal growth o Toxoplasmosis cat lovers o Others - Hepa AB, HIV, Syphillis o Rubella CHD, Rubella Titer N @ 1:10 or = immunity to rubella = notify doctor Rubella vaccine after delivery for 3 mos. No pregnancy for 3 mos. o Cytomegalo virus o Herpes Simplex virus Second Trimester : continuous growth and development (focus lengh of fetus) Fourth Month Lanugo begins to appear Buds of permanent teeth appear FHT audible via Fetuscope @ 18 20 weeks Fifth Month Quickening : 1st fetal movement Primi: 18 20, Nulli - 16 - 18 Lanugo covers the body FHT audible via stethoscope or w/out instrument Actively swallow amniotic fluid Fetus : 19 25 cm Sixth Month Skin is red and wrinkled Vernix caseosa covers the skin Eyelids open Exhibits startle reflex 3rd Trimester : period of most rapid growth and development Focus: weight Seventh Month Surfactant development

 Male: the testes begins to descent into the scrotal sac Female : clitoris is prominent and labia majora are small doesnt cover the minora Eight Month Active moro reflex Lanugo begins to disappear Sub q fats deposits, steady weight gain, nails to fingers Ninth Month Lanugos and vernix caseosa is evident in body fold Birth position assumed Amniotic fluid somewhat decrease Sole of the foot has few creases Tenth Month Bone ossification in the fetal skull Vernix caseosa is evident in body PHYSIOLOGIC ADAPTATION TO PREGNANCY Systemic Changes 1. Cardiovascular System blood volume 30 50% 1500 cc; additional 500 cc for multiple pregnancy plasma volume cardiac workload easy fatigability/ slight ventricular hypertrophy Epistaxis due to hyperemia of nasal membrane Palpitation due to SNS stimulation Physiologic Anemia/ pseudoanemia in pregnacy o Normal Value Hct : 32 42% Hgb: 10.5 14 g/dl o Criteria 1st & 3rd Trimester : Hct > 33% Hgb > 11 g/dl 2nd Trimester : Hct > 32% Hgb > 10.5 g/dl o Pathologic Anemia Iron Defficiency Anemia is the most common hematologic disorder. It affects 20% of pregnant women Assesment reveals: Pallor Slowed capillary refill = Normal = 2 3 sec Concave fingernails (late sign of progressive anemia) clubbing = chronic tissue hypoxia constipation Nursing care Nutritional instruction o Source of iron Kangkong Liver = best source due to FERRIDIN Content Red and lean meat Green Leafy Vegetables Parenteral Iron (Imferon) o Z tract IM o incorrect causes hematoma

Alert

best given 1 hour before meals (causes GI irritation) Maybe given 2 hours after meal (results to poor absorption) Given with orange juice to absorption Oral Iron Supplements (ferrous sulfate 0.3 g 3 x a day) Monitor for hemorrhage o o Iron from red meat is better absorbed iron from other sources Iron is better absorbed when taken with foods high in Vitamin C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs

Edema o Impeded venous return due to the gravid uterus o Nursing Intervention Elevate legs above the hips level Varicosities o Wear support stockings o Elevate legs Vulvar Varicosities o D/t pressure of gravid uterus o Side lying with pillow under the hips o Modified knee chest position Thrombophlebitis o Presence of thrombus in inflamed blood vessels o + Homans Sign pain on the calf upon dorsiflexion o Medical Management Anticoagulant/ HEPARIN Does not cross the placental barrier Monitor APTT Antidote: PROTAMINE SULFATE No aspirin Milk Leg/ Plagmasia Alba Dolens o Shiny white legs due to stretching of skin & hyperfibrinogenemia o Nursing intervention Check dorsalis pedis pulse (compare both) Never massage Assess for Homans sign only once

2. Respiratory System Shortness of Breath d/t gravid uterus Nursing intervention: Side-lying lateral expansion of the lungs 3. Gastrointestinal System Nausea and vomiting Morning Sickness o Due to HCG levels o Crackers 30 min before arising o AM Carb diet 30 mins

o PM small frequent meal Constipation o Due to PROGESTERONE = fluid reabsorption due to GIT motility o Nursing intervention Fluid Fiber Exercise Flatulence o Due to increased progesterone o Avoid gas forming foods Heartburn (pyrosis) o Reflux of stomach content into esophagus o Nursing Intervention Small frequent meals Sips of milk Avoid fatty and spicy foods Proper body mechanics o Waist Above Acid o Waist Below Base Hemorrhoids o Due to gravid uterus o Hot sitz bath for comfort Ptyalism o salivation o Mouthwashes to relieve 4. Urinary System Normal = + 1 sugar due to Progesterone via BENEDICTS TEST First Trimester - Frequency Second Trimester - normal Third Trimester - Frequency 5. Muscoloskeletal Calcium sources o Milk - Ca P 1 pint/ day or 3 4 servings/ day o Cheese, Yogurt, Head of Fish, Sardines, Anchovies, Brocolli Lordosis o Pride of Pregnacy Waddling Gait o Awkward gait while walking due to relaxin o Prone to accidental falls Wear low healed shoes Leg Cramps o Ca P Imbalance during pregnancy o Lumbo-sacral nerves by pressure of gravid uterus during labor o Over sex o Dorsiflex the foot affected o 3-4 servings/ 4 cups/day sa milk, sardines, dilis A. Local Chnages

Vagina o Chadwicks Sign bluish discoloration o Leukorrhea whitish gray, moderate in amount, mousy odor Cervix o Goodels Sign change in consistency of uterus o Operculum mucus plug to seal bacteria/ progesterone Uterus o Hegars Sign change in consistency Vagina Cervix Uterus Chadwicks Goodels Hegars

Problems related to the changes of Vaginal Environment a. Vaginitis - AVOCADO Trichomonas Vaginalis o Flagellated protoxzoan, Loves alakaline environment Signs and Symptoms o Greenish, cream, colored, frothy, irritably itchy, foul smelling vaginal discharge o Vaginal edema Management o Drug of choice: METRONIDAZOLE (Flagyl) Antiprotozoan Carcinogenic Not given in 1st trimester vaginal douche as substitue o 1 qt Water = 1 tbsp white vinegar o Treat partner as well to prevent reinfection o No alcohol due to antabuse effect b. Moniliasis - CHEESE Candida Albicans Transvaginal transfer in fetus Oral Trush Signs and Symptoms o White Cheeselike patches that adheres to the walls of the vagina Management o Antifungals Mycostatin Contrimazole Canisten Gentian Violet 1. Abdominal Changes Striae Gravidarum o Due to destruction of the subcutaneous tissue by the enlarge uterus 2. Skin Changes Melasma/ Chloasma o White light brown pigmentation related to melanocytes Linea Nigra o Brown pinkish line from symphysis pubis to umbilicus 3. Breast Changes

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 Due to hormonal changes Change in color and size of nipple and areola Precolostrum 6 weeks Colustrum 3rd trimester Supine with pillow under the back 4. Ovaries rest period, no ovulation 5. Signs and Symptoms of Pregnancy Presumptive Probable S/sx felt and observed by the Signs observed by mother but does not confirm the members of the the diagnosis of pregnancy health care team First Breast changes Goodels sign trimester Urinary changes Chadwicks sign Fatigue Hegars sign Amenorrhea Elevated BBT Morning sickness Positive HCG Enlarge uterus Second Chloasma Ballotement Trimester Linea Nigra Enlarge Abdomen Increase Skin Pigmentation Braxton Hicks Striae gravidarum Contraction Quickening CBQ Cancer of the Breast quadrant B Mamography 35 and above 1/ year Ballotement bouncing of the fetus may be present in uterine myoma Transvaginal Ultrasound empty bladder Abdoiminal ulrasound full bladder Placenta Grading System Grade 0 immature Grade 1 slightly mature Grade 2 moderately mature Grade 3 fully mature What is deposited? calcium VI. Psychological Adaptation to Pregnancy Reva Rubin First Trimester No tangible s/sx Feeling of surprise Ambivalence Denial of pregnancy maladaptation Developmental Task: Accept biological facts of pregnancy Health Teaching: Body changes of pregnancy and Nutrition Second Trimester Tangible s/sx Mother identifies fetus as separate entity due to quickening Fantasy Developmental Task: Accept growing fetus as a baby to nurture

Positive Undeniable signs confirmed by the use of instrument Ultrasound Evidence

etal Heart Tone etal movement etal outline etal parts palpable

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Health Teaching: Growth and development of fetus

Third Trimester Mother has personally identifies with the appearance of the baby Developmental Task: Prepare child birth and parenting the child Health Teaching: responsible parenthood, prepare babys layette, Lamaze Class Address Mothers fear let she hear the FHT

VII. Pre Natal Visit Basic Consideration 1. Frequency of Visit 1 7th mos. once a month 8 9th mos. twice per month 10th month every week 2. Personal Data Home Based Mothers Record/ HBMR determines high risk pregnancy Pseudocyesis false pregnancy appearance of presumptive & probable signs Comade Syndrome psycosomatic disorder, father experience what the mother goes through 3. Diagnosis of Pregnancy Urine Exam HCG 40 100th day; peak 60 70th day ELISA beta subunits of HCG is detected as early as 7 10th day RIA beta subunits of HCG is detected as early as 8th day Home Pregnancy Kit 4. Baseline Data Roll Over Test test of pre-eclampsia by the use of BP Weight monitoring Normal Weight Gain 1st Trimester = 1.5 3 lbs 1 lb/ mo 2nd Trimester = 10 12 lbs 4 lbs/mo 3rd Trimester = 10 12 lbs 4 lbs/mo Minimum allowable weight gain 20 25 lbs Optimal weight gain 25 35 lbs 5. Obstetrical Data a. Gravida no. of pregnancy b. Para no. of viable pregnancy Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age 1 abortion 1 pregnancy 3rd mos. G2P0 G2 T0 P0 A1 L0 c. Important Estimates 1 39TH Week, 1 miscarriage, 1 still birth, 1 2nd mo. preg G4P2 G4 T1 P1 A1 L1

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1. Nageles Rule Use to determine expected date of delivery Jan Mar +9 months +7 days Apr Dec -3 months +7 days + 1 year 2. McDonalds Rule Determines age of gestation in weeks Fundic Height x 7/8 = AOG in weeks 3. Bartholomews Rule Determines age of gestations o 3 mos above pubis symphysis o 5 mos level of umbilicus o 9 mos below xiphoid process o 10 mos level of 8th mos 4. Haases Rule Determines the length of fetus in cm. 1st half square each month 2nd half month x 5 d. Tetanus Immunization TT1 anytime or early during pregnancy TT2 1 month after TT1 3 years protection TT3 6 months after TT2 5 years of protection TT4 1 year after TT3 10 years of protection TT5 1 year after TT4 lifetime protection 5. Physical Examinations a. Danger Signs of Pregnancy Chills & Fever Cerebral Disturbances Abdominal Pain epigastric pain auro of impending convulsion Boardlike Abdomen Abruptio placenta Blurred Vission pre eclampsia Bleeding abortion/ ectopic pregnancy 1st trimester H Mole/ Incompetent Cervix 2nd trimester Placental Anomalies 3rd Trimester BP Swelling Scotoma spots in the eye Sudden gush of fluid PROM premature rupture of membrane 6. Pelvic Examination Pelvic examination or IE empty bladder, precaution 1st visit Chadwicks, Goodles sign, etc. Position : dorsal recumbent, lithotomy Pap smear done 1st visit Cytological exam determine presence of cancer cells. Result : o Class I normal o Class II A cytology without evidence of malignancy

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B suggestive of inflammation o Class III cytology suggestive of malignancy o Class IV cytology suggestive og malignancy o Class V conclusive for malignancy Most common cancer report organ : cervical cancer Most common site for pap smear external OS of cervix (squamocolumnar tissue) Common site of cervical cancer. maternal speculum (open) Stages of cervical cancer o 0 carcinoma in situ o 1 Ca strictly confined to cervix o 2 from cervix extends to the vagina o 3 pelvic metastasis o 4 affectation to bladder & rectum

7. Leopolds Maneuver Purpose: Done to determine the attitude, fetal presentation, lie, presenting part, degree of descent an estimate of the size, and no. of fetuses Procedure 1. 1st maneuver o place patient in supine position with knees slightly flexed. Put towel under head and right hip. With both hands palpate uppe4r abdomen and fundus. Assess size, shape, movement and firmness of the part o determine the presenting parts: 2. 2nd maneuver o with both hands moving down, identify the back of the fetus where the ball of the stethoscope is placed to determine FHT. o PR of mother : uterine souffl MHR o fundic souffl FHR 3. 3rd maneuver o using the right hand, grasp the symphysis pubis part using the thumb and fingers. o Assess whether the presenting part is engaged in the pelvis. o Alert! If the head is engaged it will not be movable 4. 4th maneuver o the examiner changes the position by facing the patients feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. o When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head 8is flexed and vertex presenting. Attitude relationship of fetus to one another. Full Flexion when the chin touches the chest 8. Assessment of Fetal Well-being a. Daily fetal Movement Counting (DFMC) Done starting 27th week Consideration fetal sleep wake pattern maternal food intake drug-nicotine use environmental stimuli maternal dose Cardiff count to 10 method one method currently available

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o o o

begin at the same time each day (usually in the morning after breakfast ) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs) expected findings 10 movements in 1hrs or less warning signs 10-12 movements in 1hr or less more than 1hr to reach 10 movements less than 10 movements in 12hrs longer time to reach 10 FMs than on previous days. movements are becoming weaker, less vigorous movement alarm signal <3 FMs in 12hrs warning signs should be reported to healthcare provider immediately; often require further testing. Eg. Non stress test (NST), biophysical profile (BPP)

b. Nonstress Test o to determine the response of the fetal heart rate to the stress to activity. o Indications pregnancies at risk for o placental insufficiency o Postmaturity pregnancy induced hypertension (PIH), diabetes warning signs noted during DFMC maternal history of smoking, inadequate nutrition o Procedure : Done within 30mins wherein the mother is in semifowlers position; external monitor is applied to document fetal activity; mother activates the mark button on the electronic monitor when she feels fetal movement. Attach external noninvasive fetal monitors tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected monitor until at least 2 FMs are detected in 20mins. o if no FM after 40mins provide women with a light snack or gently stimulate fetus through abdomen o If no FM after 1hr further testing may be indicated, such as a CST o Result : Noncreative Nonstress Not Good Reactive Response is Real Good o Interpretation of results Reactive result real good baseline FHR between traction beteen 120 and 160 beats per min. at least two accelerations of the FHR of at least 15 beats per min., lasting at least 15secs in a 10 to 20 min period as a result of FM good variability normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic ( FHR) and sympathetic ( FHR) nervous system; noted as an uneven line on the rhythm strip result indicates a healthy fetus with an intact nervous system o Nonreactive result not good stated criteria for a reative result are not met could be indicative of a compromised fetus requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST)

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9. Health Teachings o do nutritional assessment o daily food intake o determine habit o if folic acid lead to spina bifida/open neural tube defect o HIGH RISK MOTHERS pregnant teenagers poor compliance to health regimen extremes in wt underwt eg. Elite models overwt eg. DM/HPN low social economic status. Refer to OSWD vegetarian mothers because intake of vit B12 (Cyanocobalamin) formation of folic acid (cell DNA & RNA formation) types : strict vegetarian prone to develop anemia lacto vegetarian milk lacto-ovo vegetarian milk & egg a. Recommended Nutrient Requirement that Increases During Pregnancy Nutrients Requirements Food sources Calories Essential to supply energy for 300 calories/day above the Caloric should reflect prepregnancy daily requirement foods of high nutrient value metabolic rate to maintain ideal body weight such as protein, complex Utilization of nutrients and meet energy requirement of carbohydrates (whole grains, Protein sparing so it can be activity level vegetables, fruits) used for : nd begin in 2 Trimester variety of foods representing o growth of fetus use wt-gain pattern as an food sources for the nutrients o development of indication of adequacy of required during pregnancy structures requires calories intake no more than 30% fat for pregnancy failure to meet caloric including placenta, requirements can lead to Na 3gms/day eat in amniotic fluid, tissue ketosis as fat & protein are moderation growth used for energy, ketosis has CHON x 4K Cal been associated with fetal CHO x 4K Cal damage. Fats x 9K Cal Non pregnant: 2200 calories Pregnant: 2500 calories 2200+500 @ lactation=2700 cal Protein Essential for fetal tissue growth maternal tissue growth including uterus and breasts. Development of essential pregnancy structures Formation of RBC and plasma proteins Inadequate protein intake has been associated with onset of pregnancy induced 60mg/day or an of 10% above daily requirements for age group Adolescents have a higher protein requirement than mature women since adolescents must supply protein for their own growth as well as protein to meet the pregnancy requirement Protein should reflect Lean meat, poultry, fish Eggs, cheese, milk Dried beans, lentils, nuts Whole grains Vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids

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hypertension (PIH) Calcium-Phosphorous Essential for Growth and development of fetal skeleton and tooth buds Maintenance of mineralization of maternal bones and teeth Current research is demonstrating an association between adequate calcium intake and the prevention of pregnancy induced hypertension Iron Essential for Expansion of blood volume & RBC formation Establishment of fetal iron stores for first few months of life

Calcium of 1200mg/day representing an of 50% above pre pregnancy daily requirement 1600mg/day is recommended for adolescent 10mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous

Calcium should reflect Dairy products, milk, yogurt, ice cream, cheese, egg yolk Whole grain, tofu Green leafy vegetables Canned salmon & sardines with bones Ca fortified foods such as orange juice Vitamin D sources fortified milk, margarine, egg yolk, butter, liver, seafood

Non Pregnat:15mg/day Pregnant : 30mg/day - representing a doubling of the prepregnant daily requirement Begin supplementation at 30mg/day in second trimester, since diet alone is unable to meet pregnancy requirement 60 120mg/day along with copper and zinc supplementation for women who have low Hgb values prior to pregnancy or who have iron deficiency anemia 70mg/day of vitamin C which enhances iron absortion o Inadequate iron intake results in maternal effects anemia, depletion of iron stores, energy and appetite, cardiac stress especially during labor & birth o fetal effects availability of oxygen thereby affecting fetal growth iron deficiency anemia is the most common nutritional disorder of pregnancy

Iron should reflect liver, red meat, fish, poultry, eggs enriched, whole grain cereals & breads dark green leafy vegetables, legumes nuts, dries fruits vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, tomatoes, green peppers, broccoli or cabbage, potatoes iron form food sources is more readily absorbed when served with foods high in vit C

Zinc Essential for

15 g/day representing an of 3mg/day over prepregnant daily

Zinc should reflect

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 the formation of enzymes maybe be important in the prevention of congenital malformation of the fetus Folic acids, folacin, folate Essential for Formation of RBC & prevention of anemia DNA synthesis & cell formation; may play a role in the prevention of neural tube defects (spina bifida), abortion, abruption placenta Additional requirements Minerals Iodine Magnesium selenium

requirement

liver, meats shell fish grains, legumes, nuts should reflect Liver. Kidney, lean beek, veal Dark, green leafy vegetables, broccoli, asparagus, artichokes, legumes Whole grains, preanuts

400mcg/day representing an of more than 2x the daily prepregnant requirement 300mcg/day supplement for women with low folate levels or dietary deficiency

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

requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy

Vitamins E Thiamine Riboflavin Pyridoxine (B6) B12 Niacin

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

b. Sexual Activity Principles of sex in Pregnancy o Should be done in moderation o Should be done in a private place o That the mother should be placed in a comfortable position o It must be avoided 6 weeks prior to EDD o Avoid blowing of air during cunnilingus Contraindication in sex: o vaginal spotting 1st tri o incompetent cervix 2nd tri o placenta previa, abruption placenta 3rd tri o pre-term labor R: prostaglandin oxytocin contraction o PROM infection Changes in sexual appetite during pregnancy: o 1st tri - o 2nd tri - o 3rd tri - c. Exercise strengthen muscle to be used during the delivery process Walking best form of exercise

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 Squatting strengthen perineum & circulation to the perineum (raise the buttocks before head to prevent postural hypotension) Tailor sitting same purpose with squatting Kegel exercise strengthen pubococcygeal muscle Abdominal exercise muscle of the abdomen ( done as if blowing a candle) Shoulder circling exercise strengthen muscle of the chest Pelvic rocking exercise or pelvic tilt relieve low back pain & maintain good posture (arching back for 3 sec) Principles of exercise o must be done in moderation o must be individualized d. Childbirth Preparation Overall goal: To prepare patents physically & psychologically while promoting wellness behavior that can be used by parents & family thus, helping them achieved a satisfying & enjoying childbirth experiences. Psychological o Bradley Method Dr. Robert Bradley discoverer advocated active participation of husband during labor & delivery to serve as coach, based on imitation of nature Features: darkened room quiet & calm environment relaxation technique close eyes o Grantly Dick Read Method fear can lead to tension while tension can lead to pain. (break cycle by removing the fear-by abdominal breathing exercises & relaxation technique) Psychosexual o Kitzinger Method Dr. Shiella Kitzinger pregnancy, labor & birth & the care of the newborn is an important turning point in a womans life cycle. flowing with contractions rather than struggle with contractions Psychoprophylaxis o Lamaze Dr. Ferdinand Lamaze Prevention of pain thru mind & requires discipline, conditioning & concentration with the husbands help. Features: conscious relaxation cleansing breathe inhaling thru nose & exhaling thru mouth effleurage gentle circular massage over abdomen to relieve pain imaging Different methods of delivery o birthing chain semi-fowlers mother o bathing bed dorsal recumbent o squatting position relieve on back pain & maintain good posture o Leboyers method features : darkly lighted room

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quiet & calm environment room temp. soft music Birth under water

IX. INTRAPARTAL NOTES A. Admitting the laboring Mother Personal data Baseline data Obstetrical data Physical exams Pelvic exams B. Basic knowledge in intrapartum Theories of the Onset of Labor o Uterine Stretch Theory any hollow organ once stretched to its maximum potential will always contract & expel its content o Oxytocin Theory released by PPG, contraction effect o Prostaglandin Theory stimulation by Arachidonic acid, causes contraction of uterus o Aging Placenta 42wks (lifespan) by 36wks placenta begins to degenerate causes contraction o Progesterone deprivation theory - level of progesterone will facilitate contraction of the uterus The 4 Ps of Labor o Passenger fetus fetal head is the largest presenting part of its length Bones 6 bones (sphenoid, temporal, ethmoid) Frontal, occipital & 2 parietal bones Sutures/intermembranous spaces allows molding Molding the overlapping of the sutures of the skull to permit passage of the head to the pelvis o Sagittal bones connect to parietal bones o Cororontal bones connect to parietal & frontal bones o Lambdoidal bones connect to parietal & occipital bones Fontanels o 6 fontanels only 2 palpable anterior fontanel/Bregma diamond in shape 3cm x 4cm size close 12-18 mos post delivery 5cm hydrocephalus posterior fontanel/lambda triangular in shape 1 x 1cm size close 2-3mos post delivery Measurements of fetal head : o transverse diameter Bi-parietal - largest transverse diameter- 9.25cm Bi-temporal - 8cm

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Bi-mastoid - smallest transverse diameter - 7cm AP diameter Suboccipitobregmatic complete flexion Occipitofrontal partial flexion - 12cm Occipitotemporal largest AP diameter; hyperextended (13.5cm) Submentobrgmatic - face presentation; poor flexio Passageway vagina & pelvis Pelvis 4 main pelvic types o gynecoid round, wide, deeper, most suitable for pregnancy o android heart shape male pelvis anterior pointed post part shallow o Anthropoid oval ape-like pelvis AP wider transverse narrow o Platypelloid flat transverse oval AP narrow transverse wider c/s for delivery Problem : o mother who encounter accident o 49 o 18y/o R: pelvis not achieve its full pelvic growth Bones of pelvis 4bones o 2 hips (2 innominate bones) 3parts of 2 innominate bones Ileum lateral/side of hips o Iliac crest flaring superior border that forms prominence of hips; common site for bone marrow aspiration Ischium inferior portion o Ischial tuberosities of the area where we o Sit; basis in getting external measurement of pelvis Pubis anterior portion o Symphysis pubis junction in between o sacrum posterior portion Sacral prominence basis internal measurement of pelvis o 1 coccyx - 4 small bones that compresses during vaginal delivery universal precaution in measurement of pelvis is to empty bladder first Important Measurements o Diagonal Conjugate measure between Sacral promontory & inferior margin of the symphysis pubis Measurement 11.5-12.5 cm Basis in getting the true conjugate. o True Conjugate/Conjugate Vera Measure between the anterior surface of the sacral promontory & superior margin of the symphysis pubis. Measurement: 11.0 cm Diagonal conjugate: 1.5 cm = true conjugate. o

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Obstetrical Conjugate smallest AP diameter of the pelvis measuring 10cm or more. Tuberoischii Diameter transverse diameter of the pelvic outlet. Approx by a fist- 8cm & above.

Power the forces acting to expel the fetus & placenta involuntary contractions voluntary bearing down efforts characteristics: wave like timing: frequency, duration, intensity myometrium power of labor o Psyche/person psychological stress exist when the mother is fighting the labor experience. cultural interpretation preparation past experience support system Pre-eminent signs of labor o Preeminent Signs lightening settling of the presenting part into the pelvis brim (shooting pain radiating to the legs, urinary frequency) primi- early 2 weeks prior to EDD engagement settling of presenting part into pelvic inlet (not signs of labor) Braxton Hicks Contractions painless irregular contractions Increase Activity of the Mother Nesting Instinct (mgt: save energy) epinephrine production (hormone that the activity of the mother) Ripening of the cervix butter softness Decrease in weight 1.5-3 lbs. Bloody show pinkish vaginal discharge (blood + leucorrhea + operculum = pink in color) Rupture of membranes check FHT IE check for cord prolapse after several hrs check temp. o Premature Rupture of Membranes (PROM) contraction drop in intensity even though very painful contraction drop in frequency uterus tense &/or contracting between contractions abdominal palpitations Nursing Care: administer analgesics (morphine) attempt manual rotation for ROP or LOP bear down with contractions adequate hydration sedation as ordered o

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cesarean delivery may be required, especially if fetal distress is noted Cord Prolapse a complication when the umbilical cord falls or is washed through the cervix into the vagina. Danger Signs: PROM Presenting part has not yet engaged Fetal distress Protruding cord from vagina cerebral palsy 5 mins., irreversible brain damage mgt: CS Nursing Care Positioning knee chest or trendelenberg, place wet sterile gauze R: to make it slippery Observe for fetal distress Provide emotional support Prepare for cesarean section

Difference Between True and False Contraction True False No in intensity Pain confined in the abdomen Pain is relieved by walking No cervical changes

There is an in intensity Pain begins @ the lower back to abdomen Pain is intensified by walking Cervical effacement (thinning of the cervix, measured thru %) & dilatation (widening of the cervix, measurement thru cm) *best/major sign of true labor

Duration of Labor o Primipara 14 hrs but not more than 120 hrs o Multipara 8 hrs but not more than 14 hrs Nursing Interventions in Each Stage of Labor o First Stage: onset of contractions to full dilatation & effacement of the cervix o stage of effacement & dilatation Latent Phase: Assessment: o Dilatations 0-3 cm o Frequency 5-10 mins o Duration 20-40 mins o Intensity mild o Mother is excited, apprehensive but can communicate Nursing Care: o Encourage walking : shortens 1st stage of labor o Encourage to void q 2-3 hrs : full bladder inhibits uterine contraction o breathing (chest breathing technique) Active Phase: Assessment: o Dilatations 4-8 cm o Frequency q 3-5 mins lasting for 30-60 secs

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o Duration 30-60 secs o Intensity moderate Nursing Care: o M edications have meds ready o A ssessment include: v/s, cervical dilatation & effacement, fetal monitor, etc o D ry lips oral care (ointment), dry linens o Breathing abdominal breathing Transitional Phase: Assessment: o Dilatations 8-10cm o Frequency q 2-3 mins contractions o Duration 45-90 sec o Intensity strong o Mood of mother suddenly change accompanied by hyperesthesia (hypersensitivity of mother to touch) of the skin Management o sacral pressure, cold compress Nursing care: o T tires o I inform of progress (to relieve emotional support) o R restless support her breathing technique o E encourage & praise o D discomfort Pelvic Exams Effacement & Dilatation Station relationship of the presenting part to the ischial spine o 5 - -1 = the presenting part is above the ischial spine o Engagement 10 = the presenting part is in line with the ischial spine o (-) fetus is floating o (+) below the ischial spine Presentation o the relationship of the long axis of the fetus to the long axis of the mother. o spine relationship of the spine of the mother & the spine of the fetus

Two Types Longitudinal Lie (Parallel)/ Vertical Cephalic when the fetus is completely flexed o Vertex o Face o Brow o Chin Breech o Complete breech thigh rest on abdomen while legs rest on thigh o Incomplete breech

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Frank thigh resting on abdomen while legs extend to the head Footling Kneeling Transverse Lie (Perpendicular)/Horizontal lie Position relationship of the fetal presenting part to specific quadrant of the mothers pelvis. o ROA/LOA left occipito anterior most common & favorable position o ROT/LOT left occipito transverse o ROP/LOP left occipito posterior o o o o o L/R- side of maternal pelvis Middle presenting part ROP/ROT most common malposition ROP/LOP most painful mgt: pelvis squatting

Breech sacro place the stethoscope above the umbilicus o Chin mentum o Shoulder acromnio dorso Monitoring the contractions & fetal heart tone spread the finger lightly over the fundus to monitor the contraction Increment/Cresendro - beginning of contraction until it increases Apex/Acne height of contraction Decrement/Decresendro from height of contraction until it decreases Duration beginning of contraction to the end of the same contraction Interval from end of contraction to the beginning of the next contraction Frequency from the beginning of 1 contraction to the beginning of next contraction Intensity strength of contraction if contract blood vessel constricts; the fetus will get the oxygen on the placenta reserve which is capable of giving oxygen to the fetus up to 1min. Duration of placenta to the fetus should not exceed 1min. Significance During active phase, if to 1min should notify the AMD BP; FHT : best time to get BO & FHT just after a contraction

NURSING CONSIDERATION DURING THE FIRST STAGE OF LABOR Bath is necessary Monitor VS especially BP o Same BP = rest o Elevated = notify the physician NPO o Prevent aspiration chemical pneuminitis Enema (per hospital policy)

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Purpose Cleanse the bowel Prevent infection o 12 18 inches normal length of tube o 18 inches optimal length o Lateral sims position o If there is contraction clump the tube o If there is resistance slowly remove o Before and after administration: check FHT (120 160) and contractions Encourage mother to void Perennial preparation (rule of 7) Rest on left side lying position o Prevent supine vena cava syndrome or supine hypotension If membrane doesnt rupture amniotomy FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen For Pain o Systemic analgesic DEMEROL (Meperidine HCl) Narcotic and antispasmonic Dont give during latent phase Given @ 6-8 cm dilated WOF : Respiratory depression Narcan (Naloxone, nalorfan, nalline) o Antidote for toxicity o Injected on the baby Epidural Anesthesia WOF : Hypotension Prehydrate the client to prevent hypotension In case of Hypotension o Elevate leg o Fast Drip IV o

SECOND STAGE OF LABOR (FETAL STAGE) Complete dilatation and effacement to birth Crowning occurs PRIMI transfer to DR @ 10 cm dilatation MULTI transfer to DR @ 7 8 cm dilatation Position in lithotomy both legs at the same time BULGING OF PERENIUM surest sign of delivery initiation PANT & BLOW Breathing, fetal pushing should be done on an open glottis Respiratory alkalosis o Due to incorrect breathing o Hyperventilation o S/sx RR Lightheadedness Tingling sensation Carpopedal spasm Circumoral numbness

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Episiotomy Prevent laceration Widen the vaginal canal Shortens the 2nd stage of labor 2 types o MEDIAN Less bleeding Less pain Easy repair Possible urethroanal fistula major disadvantage o MEDIOLATERAL More bleeding More pain Hard to repair and slow healing Ironing the Perenium prevent laceration Mechanism of Labor (ED FIRE ERE) Engagement Descent Flexion Internal Rotation Extension External Rotation Expulsion PELVIS 3 Parts o Inlet AP diameter narrow, transverse wider o Cavity between inner and outer o Outlet AP diameter wider, transverse narrow LINEA TERMINALES Nursing Care MODIFIED RIGENS MANEUVER o Done by supporting the perenium with a towel during delivery o Facilitates complete flexion o Avoids laceration First intervention: Support the head and suction secretion Do not milk the cord, wait for pulsation to stop before cutting o Milking may cause too much blood going to the baby that may cause cardiac overload When there is still birth, let the mother see the baby to accept the finality of death THIRD STAGE OF LABOR (PLACENTAL STAGE) 3 10 minutes after child birth 1st sign Fundus rises CALKINS SIGN Signs of Placental Separation o Fundus becomes globular and rises calkins sign o Lengthening of the cord o Sudden gush of blood BRANT ANDREWS MANEUVER

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o o

slowly pulling the cord and wind at the clamp rapidly may cause uterine inversion

Types Placental Delivery SHULTZ (Shiny) o From center to the edges o Presenting fetal side DUNCAN (Dirty) o Form edges to center o Presenting the maternal side Nursing Considerations during placental delivery Check placental completeness o Should be 500 g Check Fundus Massage if Boggy BP Check Methergine, methylergonovine mallate (IM) Oxytocin (IV) if methergine is not present Check perenium for lacerations Assist in episioraphy Vaginoplasty/ Vaginal Landscape Virgin again FOURT STAGE OF LABOR (Recovery Stage) First 1 2 hours after delivery of placenta Maternal observation body system stabilize o 1st hour q15 min 2nd hour - q 30 min Placement of fundus o In between umbilicus and pubis symphysis o Check bladder, assist in voiding, May lead to uterine atony hemorrhage Lochia Perineum o Check REEDA R edness E dema E cchymosis D ischarge A pproximation o Fully saturated 30 40 cc o Weighing 1 cc = 1 gram Common Board Question Nursing Consideration during Recovery Flat on bed to prevent dizziness If with Chills give blanket due to dehydration Give nourishment (progression of meal) o Clear liquids gatorade, ginger juice, gelatins o Full liquid milk, ice cream o Soft diet o Regular diet Check VS/ Pain Pychic State Bonding interaction between mother and newborn

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o o

Strict 24 hours with mother Partial morning with mother, night nursery

COMPLICATIONS OF LABOR Dystocia Difficult labor related to mechanical factor Primary cause is Uterine Inertia Uterine Inertia Sluggishness of contraction Types o Primary/ Hypertonic Intense contraction resulting to ineffective pushing Management : Sedation o Secondary/ Hypotonic Slow, irregular contraction resulting to ineffective pushing Management : Oxytocin Augmentation Prolonged Labor > 20 H for primi > 14 H for multi proper pushing should be encourage if inappropriate: o may cause fetal distress o caput succedaneum o cephalhematoma o maternal exhaustion monitor contractions and FHT Precipitate Labor labor less than 3 hours causes excessive laceration leading to profuse bleeding hypovolemic shock s/sx of hypovolemic shock HYPO TACHY TACHY o HYPOtension o TACHYpnea o TACHYcardia o Cold clammy skin o Management Modified trendelenburg Fast Drip IV Inversion of Uterus Situation in which uterus is turn inside out due to: o Short cord o Hurrying of placental delivery o Ineffective fundal push Cause profuse bleeding hypovolemic Hysterectomy Uterine Rupture Rupture of uterus Caused by o Previous classical CS

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o Very large baby o Improper use of oxytocin S/sx o Sudden pain o Profuse bleeding Prepare fore TAHBSO Physiologic Retraction Ring boundary between upper and lower uterine segment BandlsPathologic Ring suprapubic depression sign of uterine rupture Amniotic Fluid/ Placental Embolism Anaphylactic syndrome of pregnancy Situation in which placental fragment and amniotic fluid enters maternal circulation S/Sx o Dyspnea o Chest Pain o Frothy Sputum o End Stage DIC Prepare for CPR, Suction and emergency etc Trial Labor Fetal head measurement = measurement of pelvis 6 hours labor allowance given to mother monitor FHT and contractions Preterm Labor labor after 20 weeks and before 37 weeks Triad signs o Premature conditions every 10 minuets o Effacement of 60 80% o Dilatation of 2 3 cm Home Management o CBR o Avoid Sex o Empty bladder o Drink 3 4 Glasses of H2O Full bladder inhibit contraction Hospital Management o If Cervix Close (Criteria: cervix is closed if it is 2 3 cm dilated only) 2 3 cm dilated, pregnancy can be saved Tocolytic Therapy Yutupar (Ritodine HCl) o Side effect maternal BP < 90/60 o Check Impt. Presence of crackles Brethine (terbutaline) Bricanyl o DOC o Side effect: sustained tachycardia o Antidote: propanolol/ inderal Mg SO4 o If cervix is dilated ( > 4cm) Give steroid dexamethasone Promote surfactant maturation

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 POSTPARTAL PERIOD

Immediately cut the cord after delivery to prevent jaundice/ hyperbilirubinemia

Puerperium 5th stage of labor, 1st 6 weeks post partum Characterize by involution Involution - return to the normal stage of reproductive organ after pregnancy Return to Normal Healing Physiologic Changes Systemic Changes Cardiovascular System o plasma volume o sudden in blood volume o elevated WBCs up to 30, 000 mm3 o hyperfibrinogenemia o orthostatic hypertension can be possible o early ambulation prevents thrombos formation steps in ambulation Flat Semifowlers Fowlers with dangling Walk with assist Genital Tract o Fundus goes down 1 finger breadth a day 10th day non palpable behind the symphysis pubis Subinvolution delayed healing of uterus containing quarters or clots of blood may lead to puerperal sepsis Management : D&C o After Pains After birth pains Multiparous breastfeeding most common to develop Position = prone Cold compress Mefenamic acid o Lochia Components Blood Deciduas WBC Microorg 3 types Rubra 1 3 days, musty, moderate amount Serosa 4 10th day, pink or brown Alba 10 21th day, crme white, amount Urinary Tract

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o o

Urinary Frequency due to urinary retention with overflow Dysuria Damage to trigone of the bladder Urine collection for culture and sensitivity Stimulate navel to urinate Palpate bladder Running water listening Pull pubic hair - stimulate cremasteric reflex

Colon o Constipation Due to NPO Bearing down may cause pain Perenium o Pain relieved by sims position o Cold compress 1st 24 hours if there is pain at episioraphy followed by warm EMOTIONAL SUPPORT 1. Taking phase 1st 3 days dependent phase passive, cant make decision tells about childbirth experience focus on: Hygiene 2. Taking Hold 4 7th day dependent to independent phase active, decides actively focus: care of newborn health teaching : Family planning 3. Letting Go Interdependent phase Redefines goals, new roles as parents May extend till the child grows Post Partum Blues 4th 5th days overwhelming feeling of depression, inability of sleep and lack of appetite 50 80% incidence rate cause by sudden hormaonal change progesterone suddenly decreases allow crying: therapeutic may lead to postpartum psychosis/ depression Postpartal Complications Hemorrhage bleeding within 24 hours postpartum Early Pospartal Hemorrhage

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1. Uterine Atony boggy fundus profuse bleeding interventions o massage the uterus o cold compress o modified trendelenburg o fast drip IV o breastfeeding to release oxytocin 2. Laceration well contracted uterus with profuse bleeding assess perenium for laceration degrees of laceration o 1st degree vaginal skin and mucus membrane o 2nd degree 1st degree + muscles o 3rd degree 2nd degree + external sphincter of rectum o 4th degree 3rd degree + mucus membrane of rectum 3. Hematoma bluish discoloration of subQ tissues of vagina or perenium candidates o delivery of very large babies o pudendal block o excessive manipulation due to excessive IE intervention o cold compress 10 20 min then allow 30 minutes rest period for 24 h 4. DIC disseminated intravascular coagulation Consumption of pregnancy (otherterm) Failure to coagulate Bleeding in the eyes, ears, nose Oozing blood Seen in cases with o Abruptio placenta o Still birth / IUFD Management o Blood transfusion of cryoprecipitate or fresh frozen plasma o hysterectomy Late Postpartum Hemorrhage Retained placental fragments manual extraction of fragments is done uterine massage D&C except for cases of o Placenta Acreta umusual attachment of the placenta to the myometrium o Placenta Increta deeper attachment of placemat to the myometrium o Placenta Percreta invasion of placenta to the perimetrium Candidates of these disorders are Grand multiparous Post CS

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All these requires hysterectomy

Infection Sources o Endogenous from normal flora of the body o Exogenous from the health care team Most common Anaerobic Streptococci Management o Supportive care o Fluid intake o TSB if there is fever/ cold compress + paracetamol may also be given o Analgesics Given on time to achieve maximum effect o Culture and sensitivity Perenial Infection Same s/ sx with infection 2 3 stitches are dislodges with purulent drainage Tx resuturing Endometritis Inflammation of the endometrium Gen s/sx of infection + abdominal tenderness Management o High fowlers facilitates drainage & localize infection o Administer oxytocin FAMILY PLANNING METHOD Guiding Principles 1. determine your own beliefs first 2. never advise a permanent method of family planning 3. informed concent 4. the method is an individual decision Natural Method accepted by the church Billings/ Cervical Mucus/ Spinnbarkeit clear watery & stretchable 13th day longest due to estrogen Basal Body Temp in the morning before arising/ 13th 14th day due to peak of progesterone LAM Lactational Amenorrhea Method prolactin inhibits ovulation breastfeeding 4 6 months no menstrual cycle bottle fed 2 3 months Sympthothermal combination of Billings and BBT most effective method Social Methods Coitus Interuptus withdrawal least effective method

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Coitus Reservatus sex w/o ejaculation Coitus interfemora between femor Calendar Method 14 days before menstrual cycle ovulation day (regular) - 4, + 4 days unsafe period Origoknause Formula ( irregular menstrual cycle) get the longest and shortest cycle subtract 18 to shortest 11 to the longest the difference is the unsafe period PILLS combined oral contraceptives preventovulation by inhibiting the anterior pituitary gland roduction of FSH and LH which are essential for he maturation and rupture of a follicle. Estrogen inhibit FSH which is responsible in the mturation of ovum. Progesterone inhibit LH which is responsible for ovulation. contains estrogen that inhibits FSH and progesterone that inhibit LH 99.9% effective 21 day feel on the 5th day of mense start taking 28 day 1st day of mense if forgotten, take 2 tablets the following day adverse effect : breakthrough bleeding if mother wants to get pregnant o wait 3 monts o another 3 months if unsuucessful before consulting gyne contraindications o chain smoking o Hypertension o DM o Extreme obesity o Thrombophlebitis Side effects (ressembles Hypertension)/ Immediate Discontinuation o Abdominal paon o Chest pain o Headache o Eye problem o Severe leg cramp Alerts on oral contraceptives : o In case a Mother who is taking an oral contraceptive for almost a long time and plans to have a baby, she would wait for at least 3mos before attempting to conceive to provide time for estrogen and progesterone levels to return to normal. If after 6months the mother did not get pregnant, consult AMD. o If a new oral contraceptive is prescribed, the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses. o Discontinue oral contraceptive if there is signs of severe headache as this are an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage. o If forget to drink pill for 1 day, take 2 pills the next day. If forget to drink pills for 2days, stop the pill and wait for the next mens.

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 Adverse reaction : breakthrough bleeding DMPA Depoprovera Contains progesterone Depomedroxy progesterone Acetate IM q 3 months never massage the site may decrease effectiveness NORPLANT 6 match stick like capsules/ rod contain progesterone sub Q planted good for 5 years Mechanical Device IUD prevent implantation alters mobility of sperm and ovum 99.7% effective best inserted after delivery and during menstruation Common complication EXCESSIVE MENSTRUAL FLOW Common problem EXPULSION OF THE DEVICE No protection against STD Side effects include o Uterine infection o Uterine perforation o Ectopic pregnacy Major indication for the use is PARITY HT: monthly check up and regular pap smear CONDOM Made up of latex Put in erected penis or lubricated vagina Prevents sperm to enter the uterus FEMALE CONDOM higher protection than that of male DIAPRAGHM Dome shaped rubberied material inserted at the cervix to prevent sperm getting inside the uterus Reusable HT : Proper hygiene o Check for holes o Must be refitted in case of weight gain of 15 lbs - - board question o Kept in place for about 6-8 Hours Board question Contraindicated to o Frequent UTI CERVICAL CAP More durable than the diaphram Could stay on place for more than 24 hours No need to apply spermicides Contraindicated to abnormal papsmear

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CHEMICAL SPERMICIDES FOAMS most effective Jellies Creams These may cause toxic shock syndrome SURGICAL METHOD Bilateral tubal Ligation o @ isthmus o 20% probability of reversal Vasectomy o Vas deferens is cut o More than 30 x or 0 sperm count or 2 x negative sperm count before it could be consider safe sex

HIGH RISK PREGNANCY HEMORRHAGIC DISORDERS General management CBR Avoid sex Prepare ultrasound determine the sac integrity Assess bleeding and approximation Assess hypovolemia Save discharge for histopathology o Determine whether the product of labor has been expelled First Trimester Bleeding Abortion termination of labor before age of viability SPONTANEOUS o AKA miscarriage o Causes 1. Chromosomal aberrations due to advanced maternal age 2. Blighted ovum 3. germ plasm defect o Natures way of expelling defective babies o Classifications : 1. Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is closed and can be saved. 2. Inevitable moderate bleeding, cramping, tissue protrudes from the cervix and the cervix is open. o Types : 1. Complete all products of conception are expelled. Mgt : emotional support

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2. Incomplete placenta and membranes retained. Mgt : D&C HABITUAL o 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. o Management (suture of cervix) 1. McDonald procedure Temporary circlage Side effect infection May have NSD 2. Shirodkar CS delivery MISSED o fetus dies; product of conception remain in uterus 4 weeks or longer o signs of pregnancy cease 1. (-) pregnancy test 2. Dark brown 3. Scanty bleeding o Mgt : induction of labor/ vacuum extraction INDUCED o Therapeutic abortion principle of 2 fold effect 1. Done when mother has class 4 heart disease Ectopic Pregnancy occurs when gestation is location outside the uterine cavity Common site : Ampulla or Tubal Dangerous site: Interstitial Unruptured Ruptured Missed period sudden, sharp severe unilateral pain, knife like Abdominal pain within 3- 5wks of shoulder pain (indicative of missed period (maybe generalized of one sided) intraperitoneal bleeding that extends to diaphragm & phrenic nerve) Scant, dark brown vaginal bleeding (+) Cullens sign bluish tinged Vague discomfort umbilicus syncope/fainting Nursing Care : o vital signs o administer IV fluids o monitor for vaginal bleeding o monitor I&O o prepare for culdocentesis to determine o hemoperitoneum Mgt : non-surgical Methotrexate

SECOND TRIMESTER BLEEDING Hydatidiform Mole / bunch of grapes Gestational Trophoblastic Disease progressive degeneration of Chorionic Villi

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gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed from the swelling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46xx. It grows and enlarges the uterus very rapidly. Cause : Unknown Assessment : o Early signs vesicles passed thru the vagina Hyperemesis gravidarum due to HCG Fundal height Vaginal bleeding (scant or profuse) o Early in pregnancy high levels of HCG Pre ecclampsia at about 12wks Vesicles look like a snowstorm on sonogram Anemia Abdominal cramping o Serious late complications Hyperthyroidism Pulmonary embolus Nursing care : o prepare for D&C o do not give oxytocin drugs due to proneness to embolism o Health Teaching: return for pelvic exams as scheduled for one year to monitor HCG and assess for enlarged uterus and rising titer could be indicative of choriocarcinoma Avoid pregnancy for at least one year Methotrexate therapy

Incompetent Cervix Management: McDonald procedure o temporary circlage of incompetent cervix. o Delivery : NSVD o SE: infection o Health teaching observe for signs of infection signs of labor Shhirodkar procedure o permanent procedure. o Delivery : caesarian section required. THIRD TRIMESTER BLEEDING PLACENTAL ANOMALIES Placenta Previa it occurs when the placenta is improperly implanted in the lower uterine segment, sometime covering the cervical os. Assessment o Outstanding sign : frank, bright red, painless bleeding o enlargement (usually has not occurred) o fetal distress o abnormal presentation

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Nursing care : o Initial mgt : NPO candidate for CS o Bedrest o prepare to induce labor if cervix is ripe o administer IV o No IE, No Sex, No enema complication : Sudden fetal blood loss o prepare Mother for double set up DR is converted to OR

Abruptio Placenta it is the premature separation of the placenta from the implantation site. It usually occurs after the twentieth week of pregnancy Cause: o Cocaine user o Severe PIH o Accident Assessment: o Outstanding sign : dark red & painful bleeding o concealed hemorrhage (retroplacental) o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction o rigid boardlike abdomen o severe abdominal pain o dropping coagulation factor (a potential for DIC) o sx : bleeding to any part of the body. Mgt : for hysterectomy General Nursing care : o infuse IV, prepare to administer blood type and crossmatch o monitor FHR o insert Foley catheter o measure bllod loss; count pads o report s/s of DIC o monitor v/s for shock o strict I&O Placental Succenturiata 1 or 2 lobes connected to the placenta by a blood vessel Placenta Bipartita placenta divided into 2 lobes HYPERTENSIVE DISORDER Pregnancy Induced Hypertension o HPN after 24wks resolved 6wks postpartum which cause pregnancy. o Types : o Gestational HPN HPN without edema & proteinuria. Mgt : monitor BP o Pre-eclampsia triad o sx : HPN with edema, proteinuria or albuminuria (HEP/A) which cause is unknown or idiopathic but multifactoral primis d/t 1st exposure to chorionic villi multiple pregnancies due to exposure to chorionic villi

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Mothers of low socio-economic status due to protein intake Teenagers d/t low compliance to protein intake HELLP syndrome hemolysis with elevated liver enzymes & low platelet count

Transitional Hypertension HPN between 20-24wks Chronic or Pre-existing Hypertension o HPN before the 20th wk not resolved 6wks postpartum o 3 types of pre-eclampsia o Sign of pre-eclampsia : o > 30mmHg systolic o > 15mmHg diastolic o Roll over test 10-15min side lying Then supine Then take BP o mild pre-ecclampsia 140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : wt, inability to wear wedding ring due to developing edema Signs present cerebral & visual disturbances, epigastric pain to liver edema and oliguria usually indicates an impending convulsion Before convulsion : if you see sign of epigastric pain, 1 mgt is to place tongue depressor and put the side rales up During convulsion : observe the Mother for safety After convulsion turn to side to facilitate drainage o Severe pre-ecclampsia 160/110, +3 or +4, proteinuria, visual disturbances Nursing care P promote bedrest Prevent convulsions by nursing measures to O2 demand & facilitate Na excretion Management: quiet & calm environment, minimal handling, avoid moving the bed Heat Acetic Acid determine protein in the urine Prepare the following at bedside o tongue depressor, Suction machine & O2 tank E ensure high protein intake (1g/kg/day) Na in moderation A antihypertensive drug with hydraluzine C CNS depressant with Mg Sulfate for anti-convulsion Mgt : evaluate for hypermagnesiumenimia E evaluate physical parameters for Magnesium Sulfate toxicity : B BP U Urine output R RR P Patellar reflex is absent Antidote : Ca gluconate o Eclampsia with seizure BUN sign of glumerular damage

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Diabetes Mellitus o cause by absent & lack of Insulin o Action of Insulin is to facilitate transfer of glucose into the cell o Dx test : 50gm 1hr Glucose Tolerance Test o 130 hyperglycemia o 70 hypoglycemia o 80-120 euglycemia o if > 130mg/dl, the Mother needs to undergo a 3hr GTT o Maternal Effects : o hypoglycemia during the 1st trimester development of the brain sinisipsip ng fetus yung glucose ng nanay. o Hyperglycemia during the 2nd & 3rd trimester HPL effect Mgt : give insulin. OHA are teratogenic. 1st trimester - insulin, 2nd trimester - insulin, post partum drop suddenly Frequent infections eg. Moniliasis Polyhydramnios Dystocia o Fetal Effects : o hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd trimester thru facilitated diffusion o Macrosomia/LGA .4000gms o IUGR due to prolonged DM o Preterm birth promote still birth o Newborn Effects : o Hyperinsulinism and Hypoglycemia 40mg/dl Normal : 45-55mg/dl Borderline : 40mg/dl Sx : pitched shrill cry, tremors, jitteriness Dx test : heel stick test to check glucose levels o Hypocalcemia < 7mg/dl Calcemic tetany Tx : Ca gluconate Heart Disease o Classification : o I no limitation o II Slight limitation, ordinary activity causes fatigue good prognosis can deliver vaginally Mgt : sleep of 10hrs/day, rest 30mins after meals

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III moderate limitation, less than ordinary activity causes discomfort poor prognosis. Good for vaginal delivery Mgt : early hospitalization by 7-8mos IV marked limitation of physical activity for even at rest there is fatigue poor prognosis. Good for vaginal delivery only with regional anesthesia. Low forceps delivery when unable to push & to shorten the stage of labor Mgt : therapeutic abortion, high semi- fowlers position, left side lying, no valsalva maneuver - may trigger cardiac arrest, heparin therapy required, antibiotic therapy for prevention of sub acute bacterial endocarditis

INTRAPARTAL COMPLICATIONS Cesarean Delivery Indications a. multiple gestation b. diabetes c. active herpes II d. severe toxemia e. placental previa f. abruption placenta g. prolapse of the cord h. cephalo pelvic disproportion and primary indication i. breech presentation j. transverse lie procedure : o classical vertical incision o low segment bikini, for aesthetic purposes. Can have vaginal birth after c/s Genotype genetic make-up Phenotype Physical appearance Karyotype pictorial analysis of individual chromosome for detecting chromosomal abnormalities Autosomal Dominant huntingtons chorea retinoblastoma achondroplasia polydactyl Autosomal Recessive sickle cell Cystic fibrosis Celiac PKU Galactosemia X- Linked Recessive Hemophilia Duchennes muscular dystrophy Color blindness X Linked Dominant Rickettes

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