NCM 101

Reproductive Health

Definition of terms:
HEALTH – state of physical, mental, social well – being and not merely the absence of
disease or infirmity.
REPRODUCTIVE HEALTH – addresses the reproductive processes, functions and system at
all stages of life.
REPRODUCTION – biological process where a new individual is produced.

PHILIPPINE REPRODUCTIVE HEALTH (Cairo, Egypt – 1994)

- Established by the AO 1-As.1998 by DOH
- AO 43, s.1999
o Was issued adopting reproductive health policy to integrate reproductive health
services in all health facilities as part of basic package of health services and
thus ensuring more efficient and effective referral system from primary to
tertiary, public and private facilities.

Main Objectives:
1. Reducing maternal mortality rate.
2. Reducing child mortality.
3. Halting and reserving spread of HIV and AIDS
*HIV – blood transfusion, trans – placental, sexual intercourse.
- Abstinence
- Be faithful
- Condom
- Drug avoidance
- Education campaign
- F*** yourself
4. Increasing access to reproductive health information and services.

TEN ELEMENTS OF REPRODUCTIVE HEALTH

1. Family planning.
2. Prevention and management of reproductive tract infections (RIH) including STI’s and
HIV/AIDS.
*Benzathine penicillin
3. Maternal and child health nutrition (MSC & N).
4. Adolescent reproductive health (ARH).
5. Prevention and management of abortion and its complications (PMAC).
6. Education and counseling on sexuality and sexual health, men’s reproductive health
(MRH) and involvement.
7. Prevention and management of breast and reproductive tract cancers and other
gynecological conditions.
8. Violence against women and children (VAW).
9. Prevention and management of infertility and sexual dysfunction.

THE MENSTRUAL CYLCE / FEMLE REPRODUCTIVE CYCLE

A. Purpose: to bring an ovum to maturity and renew a uterine tissue bed that will be
responsible for its growth should it be fertilized.
B. Definition of Terms:
CLIMACTERIC – period of a woman’s life when she is passing from a reproductive to a
non – reproductive state, with regression of ovarian function.
MENSTRUATION – periodic vaginal discharge of bloody fluid from non – pregnant uterus
that occurs from the age of puberty to menopause.
 MENSTRUAL CYCLE – a complex interplay of events that occurs simultaneously in the
uterus, hypothalamus and pituitary glands and the ovaries that results in ovarian and
uterine preparation for pregnancy.
MENOPAUSE – cessation of menstrual cycle.
OVULATION – periodic ripening the discharge of ovum from the ovary, usually 14 days
before the menstrual flow.
MITTELSCHEMERZ – localized lower abdominal pain that coincides with ovulation.
SPINNBARKEIT – property of the cervical mucous to stretch a distance before breaking.
FERNING – a ferning pattern of cervical mucus occurs with high estrogen levels.
C. Characteristics of a Normal Menstrual Cycle
MENARCHE
Onset: 11 – 13 years old
Range: 9 – 17 years old
INTERVAL
Average: 28 days
Unusual: 23 – 35 days
DURATION
Average: 2 – 7 days
Range: 1 – 9 days
AMOUNT
30 – 80 mL / menstrual period
Saturating pad / tampon in less than an hour is heavy bleeding.
COLOR
Dark red; blood mucus, endometrial cells.
ODOR
Similar to that of marigolds.
D. Physiology of Menstrual Cycle
1. Hypothalamus
a. Factors affecting GnRH release
i. Estrogen
ii. Progesterone
iii. Prolactin
iv. FSH
v. LH
b. Release GnRH (LNRH) which initiates menstrual cycle.
c. Sensitive to estrogen produce by adrenal glands during childhood.
d. Becomes less sensitive to estrogen feedback beginning puberty.
2. Pituitary Gland
a. Produces 2 hormones that influence the menstrual cycle.
b. FSH, active early in the cycle and responsible for the maturation of the ovum.
c. LH, most active hormone at the midpoint of the cycle, responsible for ovulation
and growth of the uterine lining during the second half of the menstrual cycle.
*Adenohypophysis – anterior pituitary gland
3. Ovary
a. FSH and LH cause growth in the gonads.
b. Ovarian cycle occurs.
i. Ovarian Cycle
1. Follicular Phase
• Period during which an ovum matures.
• FSH and LH levels rise slightly.
• Primordial follicle produces a clear fluid (follicular fluid), high in
estrogen (estradiol) and some progesterone (Graafian follicle).
2. Ovulatory Phase
• Marks the beginning of the luteal phase and occurs about 14 days
before the next menstrual period.
 3. Luteal Phase
• LH acts on the old follicle causing it to produce a bright yellow fluid
(Lutein), high in progesterone and some estrogen (corpus luteum).

4. Uterus
a. Menstrual cycle occurs.
i. Menstrual Cycle
1. Proliferative Phase
• Estrogenic, Follicular, Post – menstrual Phase
• Day 5 – 14
• The endometrium proliferates approximately eightfold
2. Secretory Phase
• Progestational, Luteal, Premenstrual Phase
• Blood vessels and endometrium become corkscrew or twisted in
appearance and dilated with quantities of glycogen, proteins, lipids
and minerals.
3. Ischemic Phase
• The blood supply to the functional endometrium is blocked and
necrosis develops.
• The functional layer separates from the basal layer and menstrual
bleeding begins making day 1 of next cycle.
4. Menstrual Phase
• Shedding of the functional 2/3 of the endometrium.
• The basal layer is always retained.
• Regeneration begins near the end of the cycle from cells derived
from the remnants in the base.

DEVELOPMENTAL STAGES
A. Ante - partal
- A term used to describe the period before labor or birth.
1. FETAL DEVELOPMENT
a. Fertilization (zygote)
• Also referred to as conception, impregnation, fecundation.
• The union of an ovum and spermatozoa which usually occurs in the
outer third layer of fallopian tube (ampulla).
• “The Beginning of Pregnancy”
• Ovum: Life – 24 – 48 hours
Zona Pellucida – a ring of muco polysaccharide fluid.
Corona Radiata – a circle of cells.
• Spermatozoon: Life – 48 – 72 hours
Capacitation – final process that a sperm must undergo to be
ready for fertilization.
Hyaluronidase – proteolytic enzyme produced by the sperm
to…
Semen – 2.5 mL (50 – 200 million / mL)
Average of 400 million/mL/ejaculation
b. Implantation (embryo)
• Contact between the growing structure and the uterine endometrium.
• Occurs approximately 8 – 10 days after fertilization at the upper part
of the uterus.
• It takes 3 – 4 days for the zygote to journey to the uterus where
mitotic cell division happens.
• Floats in the uterus for 3 – 4 days.
 • MORULA: because of the outward – bumpy appearance
o “Morus” mulberry; 15 – 50 cells
• BLASTOCYST: one which will attach to the uterine wall.
o Trophoblast – outer layer that will form the placenta and
membrane.
o Embryoblast – forms the embryo.
• Implantation Bleeding – mistaken as menstrual period.
- 4 weeks late calculation of pregnancy.
c. Stages of Fetal Development
i. Fertilized Ovum
• From conception through first 2 weeks of pregnancy.
• Nidation complete by the end of this period.
• Embryo: 2nd – 8th week (critical time for development).
• Fetus: end of the 8th week to termination of pregnancy.
• Organ systems develop from 3 primary germ layers.
a. Ectoderm – brain and spinal cord, peripheral nervous
system, pituitary gland, sensory epithelium of the eye,
ear, and nose, epidermis, hair nails, subcutaneous
glands, mammary glands and tooth enamel.
b. Mesoderm – cartilage, bone, connective tissue, muscle
tissue, heart, blood vessels, blood cells, lymphatic
system, spleen, kidneys, adrenal cortex, reproductive
system and lining membranes (pericardial, pleural,
peritoneal).
c. Endoderm – lining of GIT, RT, urinary bladder, urethra
and ear canal, tonsils, thyroid, parathyroid, thymus,
liver, and pancreas.
ii. Measurements of Length of Pregnancy
• Days: 267 – 280
• Weeks: 40, plus or minus 2
• Months: lunar (10); calendar (9)
• Trimester: 3
iii. Expected date of Delivery (EDC/EDD)
• Nagele’s Rule – most common method in computing EDD.
a. Add 7 days to the first day of the last normal
menstrual period.
b. Subtract 3 months.
c. Add 1 year.
• McDonald’s Rule
a. fundic height (cm) x 2/7 = AOG in lunar months.
b. Fundic height (cm) x 8/7 = AOG in weeks.
• Bartholomew’s Rule
a. 12 weeks – level of umbilicus
b. 16 weeks – halfway between umbilicus and symphysis
pubis.
c. 20 weeks – level of umbilicus.
d. 24 weeks – 2 fingers above the umbilicus
e. 28 – 30 weeks – halfway between umbilicus and
xyphoid process.
f. 40 weeks – at 34 weeks due to lightening.
iv. Time Table
Date Development
4 weeks All systems in rudimentary form; heart chambers formed and is beating.
L= 0.4 – 0.5 cm long; Wt. = 0.4 g
8 weeks Some distinct features in face, head large in proportion to rest of body, some
movement.
L = 2.5 cm; Wt. = 0.4 g
12 weeks Sex distinguishable; ossifications in most bones, kidneys secrete urine, able to
such and swallow.
16 weeks More human appearance; earliest movement likely to be felt by mother.
L = 11.5 – 13.5 cm; Wt. = 100 g.
20 weeks Vernix caseosa and lanugos appear heart rate audible, bones hardening.
L = 16 – 18.5 cm; Wt = 3oo g.
24 weeks Body well proportioned; skin red and wrinkled, hearing established.
28 weeks Infant viable, but immature if born at this time, body less wrinkled, appearance of
nails.
L = 27 cm; Wt = 1100 g.
32 weeks Subcutaneous fat beginning to deposit, L/S ration in lungs now 1.2:1, skin smooth
and pink.
36 weeks Lanugos disappearing; L/S ratio 2:1
L = 35 cm; Wt = 2200 – 2900g
40 weeks Full term pregnancy. Baby is active, with good muscle tone; strong suck reflex,
little lanugos.
L = 40 cm; Wt = 3200 g or more.

d. Products of Conception
i. Fetus
ii. Membranes (bag of waters) – 2 fetal membranes composed of the
amnion (inner membrane) and the chorion (outer membrane).
iii. Amniotic Fluid – clear, yellowish, fluid surrounding the developing
fetus.
• Derived from fetal urine and fluid transported from the
maternal blood across the amnion.
• Increases until 500 – 1500 mL at term
• Protects fetus and promote normal prenatal development.
• Allows free movement.
• Maintains temperature.
• Provides oral fluid.
• *Volume is important factor in assessing fetal well – being.
a. Oligohydramnios – abnormal small quantity of fluid
which is less than 500 mL.
1. associated with poor fetal lung development
malformations that results from compression of
fetal parts.
2. may occur because the kidneys fail to develop,
urine excretion is blocked, or placental blood
flow is inadequate.
b. Hydramnios (Polyhydramnios) – more than 2000 mL of
amniotic fluid.
 May occur when the fetus has a sever
malformation of the CNS or GIT that prevents
normal ingestion of amniotic fluid.
iv. Placenta – is a thick, disk shaped organ composed of 15 – 20
cotyledons (maximum of 30).
• Fetal side, smooth with branching vessels covering the
membrane – covered surface.
• Maternal side, rough where it attaches to the uterus.
 • Major functions include; metabolic, transfer of substances
between mother and fetus, endocrine.
• Presentation: Duncan (dirty) or Schultz/e (shiny).
• Hormones produce by the placenta:
a. Human Chorionic Gonadotropin (HCG) – ensures a
continued supply of estrogen and progesterone
needed to maintain the pregnancy.
 Basis of pregnancy test.
b. Chorionic Somatomammotropin or Human Placental
Lactogen – similar to a growth hormone and stimulates
maternal metabolism to supply needed nutrients for
fetal growth.
 Prepares breasts for lactation.
c. Progesterone – maintains the endometrium
 Decreases the contractility of the uterus.
 Stimulates development of breast alveoli and
maternal metabolism.
d. Estrogen – stimulates uterine growth and utero
placental blood flow.
v. Umbilical Cord
• Lifeline between fetus and placenta.
• Contains 2 arteries and 1 vein (AVA)
• Cushioned by a soft substance called WHARTON’s jelly to
prevent obstruction due to pressure.
• No pain receptors in the umbilical cord.
• At term: 2 cm in diameter; 30 – 90 cm in length.
e. Fetal Circulation
i. 2 arteries – carry deoxygenated blood.
ii. 1 vein – carry oxygenated blood
iii. Ductus Venosus – connects umbilical vein and inferior vena cava,
largely bypassing liver and closes after birth.
iv. Foramen Ovale – allows blood flow from right atrium to left atrium,
bypassing lungs and closes immediately after birth.
v. Ductus Arteriosus – allows blood flow from pulmonary artery to
aorta, bypassing fetal lungs.
vi. Diagram of Fetal Circulation
2. MATERNAL CHANGES DURING PREGNANCY
 Psychological Changes of Mother
o 1st Trimester – accepting pregnancy.
o 2nd Trimester – accepting the baby.
o 3rd Trimester – preparation for parenthood.
 Couvades’ Syndrome – father experiences fatigue, nausea, vomiting,
back pain.
 Pregnancy is a period for:
o The needs of the fetus.
o Meeting the stress of pregnancy and labor.
 Changes during pregnancy can be:
o Metabolic – chemical
o Physiological – function
o Anatomical – physical
 Reproductive System
• Uterus – increases from 60 gm to 1000gm
 o Hypertrophy of myometrial cells growing
fetus.
o 1/6 of maternal blood volume is contained
in uterus at the end of the pregnancy.
o Braxton Hick’s contraction – painless
intermittent contractions.
o Uterine position over time – weeks.
• Cervix – mucous plug; seals cervix
o Goodell’s sign: softening the cervix
o Chadwick’s sign: bluish discoloration of the
cervix, vagina, and labia.
o Hegar’s sign: softening of the lower uterine
segment.
• Breasts – enlarged and more nodular
o Nipples are erectile.
o Areolas darken
o Colostrums – last trimester
 Respiratory System
• Increase in O2 consumption and volume of air.
• Diaphragm is pushed upward; breathing changes
from abdominal to chest.
 Cardiovascular System
• Blood volume increases to 45 % above
nonpregnant level.
• Cardiac output increase.
• Pulse increases by 10 – 15.
• Dependent edema and venous stasis.
• Delusional/pseudo anemia
• Supine Hypotensive Syndrome – compression of
the vena cava causing blood pressure to fall
• As long as a woman has started having menstrual
cycle, she has to take iron supplements because
she’s at risk of pregnancy.
• Supine Hypotensive Syndrome – when woman lies
on her back, circulation to the placenta may also
be reduced by increased pressure on the woman’s
aorta.
o Signs and Symptoms
 Faintness
 Lightheadedness
 Dizziness
 Agitation
o Nursing interventions
 Turning to left side
 If the woman must remain flat for
any reason, a small towel roll placed
under one hip will also help to
prevent supine hypotensive
syndrome (right side).
 Urinary System
• Glomerular filtration rises by 50 % due to increase
cardiac output.
• Glycosuria – excretion of glucose in the urine.
 • Frequency during and third trimester due to
pressure on bladder.
• The diameter of the uterus and the bladder
capacity increase causing stasis.
• Susceptible to UTI.
• Gestational DM – glycosuria.
 Gastrointestinal
• Morning sickness – occurs due to elevated levels
of estrogen and progesterone.
• *Cardiac sphincter is relaxed due to high levels of
progesterone; mother is more prone to GERD
(Gastro-esophageal Reflux Disease).
• What can you do about morning sickness?
o Eat crackers, toast or dry cereal.
o Eat small, frequent meals (there is tie for
digestion and absorption.)
o Limit fried, fatty and spicy foods (triggers
production of HCL).
o Drink liquids in between meals.
o Have a snack before bed.
o Sleep in a well ventilated room.
 Musculoskeletal System
• Joints of pelvis relax due to hormone – relaxin.
• Waddling gait
• Center of gravity changes
• Diastasis recti – separation of rectus abdominis
muscle.
• Lordosis is common due to the change of the
body’s center of gravity; PRIDE OF PREGNANCY.
 Integumentary
• Chloasma – increases pigmentation over bridge of
nose and cheeks; THE MASK OF PREGNANCY.
• Linea Nigra – mark vertical line that appears on
the abdomen during the pregnancy.
• Linea Alba – white line
• Striae Gravidarum – stretch marks
 Weight Gain
• Normal Range
o Pre – pregnant BMI – 25 – 35 pounds (30 is
ideal)
o Baby – 8 pounds
o Placenta – 2 – 3 pounds
• Overweight: 28 – 40 pounds
• Underweight – 15 – 25 pounds
3. Diagnosis of Pregnancy
• Presumptive Signs (Subjective)
o NASALO Q B Sperm?
 Nausea and vomiting
 Amenorrhea
• Primary amenorrhea – congenital anomaly; absence of
uterus or failure of the ovary to receive or maintain egg
cells.
 • Secondary Amenorrhea – cessation of menstrual cycle;
menopausal stage; normal cycle: 28 days; > 3 months
without cycle = secondary amenorrhea.
• Oligoamenorrhea – beyond 35 days without cycle.
 Skin discoloration
• Chloasma or melasma
• Melanin stimulating hormone – increased due to increased
progesterone and estrogen.
 Abdominal changes
• There is uterine enlargement
• Linea nigra – below the xyphoid process to symphysis
pubis.
• Striae Gravidarum – Lines of Pregnancy
 Laging pagod (fatigue)
 Overactive bladder (frequent urination)
 Quickening – first movement felt by the mother
 Breast changes – darkening of areola; nipple is more erectile.
• Probable Signs
o Noted by the health care provider but are still not conclusive for
pregnancy.
o CGURO…Pregy B U?
 Chadwick’s sign – bluish purplish discoloration of the vagina
 Goodell’s sign – softening of the cervix
 Uterine softening (Hegar’s sign) – lower part of the uterus.
 Rising and rebound of fetus when tapped (Ballottement).
 Outline of the fetus felt through palpitation.
 Braxton hick’s contraction – painless and irregular.
 Ultrasound – shows gestational sack.
• Positive Signs
o Conclusive for pregnancy
o U my gosh! Buntis Me!
 Ultrasound reveals fetal outline (sonogram).
 Beating of the fetal heart audible (fetal heart tone).
• Fetal heart beat – Doppler at 10 – 12 weeks; Stethoscope
(18 – 20weeks).
• Right lower quadrant.
 Movement of the fetus felt by the examiner (fetal movement)
• Fetal image through ultrasound scanning.
 Health Habits during Pregnancy
o Nutrition
 Increase 300 kcal/day
 Diets – increase calcium, iron, protein.
o Weight gain
 Increase to 25 – 35 pounds
 1st trimester – total gain of 5 pounds.
 4 – 8 months – per month – weight gain of 2 – 3 pounds
 9th month gain 1 pound/week.
o Hygiene practices
 Paying attention to appearance – promote physical comfort.
 Have dental check – ups
 Avoid very cold or very hot baths.
o Rest and sleep
  Recommend 8 hours of sleep at night.
 At least one 15 – 30 min with or without sleep.
o Physical activity
 Can and should stay active.
 Avoid contact sports but do keep active.
 Nutrition during Pregnancy and Labor
o Before pregnancy, if you were:
 Underweight – gain 28 to 48 pounds.
 Normal weight – gain 25 – 35 pounds.
 Overweight – gain 15 – 25 pounds
 Obese – gain 15 – 18 pounds.
o Simple diffusion – transport oxygen to fetus
o Organogenesis – 1st trimester.
o Nutritional Requirement
 Calorie increase: 800 kcal per day
 Growth of the fetus
 Placenta
 Amniotic fluid
 Maternal tissue
o Important Nutrients Needed by Pregnant Women
 CHON – 60 mg/day: metabolism – development of muscles.
 Sources: meat, fish, poultry, and dairy products, beans.
 Calcium – 1200 mg: dairy products, nuts dried fruits, canned salmon
and sardines.
 1000 – 1200 mg daily intake.
 Iron – 30 mg/day: dried beans, fish, dried fruit, liver, nuts.
 Iron is found in two forms:
o Heme – red and organ meats.
o Non heme – plant products.
 Folic Acid – reduce incidence of neural tube defects.
 RDA: 400 mcg (0.4 mg): liver
o May cause meningomyelocele.
 Fluids – 8 – 12 glasses/day; limit caffeine consumption to 2 cups/day.
 Sodium Intake – restricted: edema and gestational HPN.
 Iodine salt – better brain development.
o Teenage Pregnancy
 Girls growth and growth of fetus = difficult meeting nutritional needs.
 Before pregnancy if you were:
 Underweight: gain 35 – 40 pounds
 Normal weight: gain 30 – 35 pounds
 Overweight: 25 – 30 pounds
o Health Hazards to Avoid During Pregnancy
 STI’s
 AIDS
 Drugs – medications: should be advised by woman’s doctor and
monitored.
 Alcohol: can cause FAS and the baby will be shorter, weigh less,
have a smaller head and have some heart problems.
 Nicotine: can cause lack of oxygen to the unborn child and cause
the baby’s brain to develop abnormally.
  Illegal drugs: can cause sever birth defects. If the woman is
hooked on drugs, chances are the baby is too. The baby will go
through a “withdrawal” once it is born.
 Radiation exposure
 Environmental pollution
o Classification of Pregnancy
 Gravida – number of times pregnant regardless of duration, including
present pregnancy.
 Primigravida – pregnant for the first time.
 Multigravida – a woman who has 2 or more pregnancy.
 Nulligravida – a woman who has never been pregnant.
 Para – number of pregnancy that lasted more than 20 weeks regardless
of outcome.
 Primipara – a woman who has given birth to a baby beyond 20
weeks of gestation.
 Multipara – had two or more births to a baby beyond 20 weeks
of gestation.
 Nullipara – has not given birth to a baby beyond 20 weeks of
gestation.
 Postdate/post term – beyond 42 weeks of gestation.
 Preterm – has reached 20 weeks of gestation but before completion of
37 weeks of gestation.
 Term – a pregnancy from beginning 38th week of gestation to the end of
the end of the 42nd weeks of gestation.
 Viability – capacity to live outside the uterus approximately 22 – 24
weeks since LMP or weight of fetus is greater than 500 grams.
 TPAL – para subdivided to reflect births that went Term, Premature
births, Abortion, and Living children.
4. FETAL ASSESSMENT
• Fetal diagnostic tests
o Used to:
 Identify or confirm existence of risk factors.
 Validate pregnancy.
 Observe process of pregnancy.
 Identify genetic abnormalities.
o Chronic Villi Sampling (CVS)
 Provides chromosomal studies of fetal cells.
 Getting a sample of the chronic villus (placental tissue)
 Done at 10 – 12 weeks of gestation
 1 % risk of confined placental mosaicism
o Amniocentesis
 Small amount of fluid from the amniotic sac is withdrawn to look
for the birth defects and chromosome problems.
 15 – 20 weeks gestation
 Detects: down’s syndrome, spina bifida, fetal lung maturity.
 For Rh – incompatibility.
o Ultrasound / sonogram
 Sound waves bounce of the fetus to produce an image of the
fetus inside the womb.
 Determines gestational age.
 Diagnose multiple pregnancies.
 Identify congenital anomalies
  Fetal viability.
• Types:
o Trans vaginal UTZ – used during early pregnancy.
o Standard UTZ (2D)
o 3D – more detailed
o Doppler UTZ – provides information about blood
flow and assess heart beat.
 Cleft lip
 Gastrochisis
o Fetal Kick Counts
 Determines FHR. Normal: 120 – 160 bpm
 Recognizes periodic change in FHR.
 Determines frequency and duration of contractions.
• 10 movements in 2 hours.
o Percutaneous Umbilical Blood Sampling (PUBS) or cordocentesis
 A blood sample is withdrawn from the umbilical cord for testing.
 Specifically use to diagnose disease of the blood. E.g.
thrombocytopenia
 Can receive weekly
• Infusion of platelets until delivery.
o Nonstress test (NST)
 Accelerations in heart rate accompany normal fetal movement.
 Use to assess FHR on a frequent basis in order to ascertain fetal
well – being.
 Performed after 28 weeks gestation.
o Contraction Stress Test
 Monitor fetus response to contraction to determine well being
obtain through:
• During spontaneous Braxton Hick’s contraction
• Nipple stimulation CST: massage or rolling of one or both
nipples to stimulate uterine contraction.
• Oxytocin challenge test: infusion of calibrated dose of IV
oxytocin.
 The woman must have at least 3 contractions, 40 seconds in
duration in a 10 minute period for interpretation of the CST.
 Fetus can tolerate labor.
 Consistent late deceleration
 May try induction or CS birth.
o Biophysical Profile
 Measurement of 5 biophysical variables to determine fetal well –
being:
• FHR acceleration
• Breathing
• Body movements
• Muscle tone
• Amniotic fluid volume
• Leopold’s Maneuver
o Purpose: to determine the position and presentation of the fetus
: identify if the pelvis measurement is appropriate enough for
NSD.
o Procedures:
 Preparation:
 • Ask pregnant mother to void before you palpate so as to
make her comfortable and fetal contours are not obscured
by a distended anterior urinary bladder.
• Should be supine with knees flexed slightly to relax the
abdominal muscle from contracting or lightening
• Warm hands, uncover the abdomen. Use firm, gentle
motion in executing the 4 maneuvers.
st
 1 Maneuver
• Face head part of the woman.
o Palpate superior surface of the fundus or upper part
of abdomen with tips of both hands.
o Form a precise opinion as to what fetal part has in
this area.
 Fetal head is hard, firm, round, moves
independently of the trunk.
 A buttock feels softer, is symmetric and has
small bony…
o
 2nd Maneuver
• Face head part of the woman
• Determine the location of the fetal back.
o Fetal back is smooth, hard, firm, resistant surface.
o Fetal extremities feel like small irregularities and
protrusion.
rd
 3 Maneuver
• Pawlick’s grip
• Still facing the head part of the woman.
• Determine what fetal part is lying above the inlet or lower
abdomen.
th
 4 Maneuver
• Face the foot part of the woman.
• Locate the fetus brow.
• Degree of flexion.
• Focus Area for Abdominal Palpation
o Assess fundal height
 Fundal height (cm) approximate weeks of gestation.
o Assess fetal lie
 Relationship of the long axis (spine) of the fetus to the long axis
of the mother.
o Assess fetal presentation
 Part of the fetus that enters the pelvic inlet first and leads
through the birth canal during labor term.
o Asses fetal vertex position
 LOL – 40 %
 LOA – 12%
 LOP – 3%
 ROL – 25%
 ROA – 10%
 ROP – 10 %
o Assess fetal descent
 Is vertex engaged
 4 presenting parts
 • Occiput – vertex presentation
• Chin (mentum) – face presentation
• Sacrum – breech presentation
• Scapula (acromion) – shoulder presentation.
5. COMPLICATIONS DURING PREGNANCY
• Hemorrhagic Conditions
o Abortion
 The spontaneous or induces abortion of a pregnancy before
viability of the fetus.
 Viability is defined as 20 – 24 weeks of gestation and a weight of
500 g.
 Induced – voluntary method of termination.
• Factors:
o Preserve the health of the mother.
o Prevent the birth of an infant with severe genetic
defects.
o End pregnancy cause by rape or incest.
o Economic or social reasons.
• Methods
o Vacuum aspiration
o Pills (drugs)
 Mifepristone (RU [roussel u-claf] 486)
 Misoprostol (cytotec) – prostaglandin
 Methotrexate (cancer drug)
 Spontaneous Abortion
• Commonly known as miscarriage.
• Factors:
o Chromosomal abnormalities
o Faulty implantation
o Teratogenic substances
o Placental abnormalities
o Incompetent cervix
o Chronic maternal disease
o Maternal infections
o Endocrine imbalances
• Classification
o Threatened
 Unexplained bleeding and cramping, cervix
is closed and membranes are intact.
o Inevitable
 Increase bleeding and cramping, the cervix
begins to dilate and the membranes may
rupture.
o Incomplete
 Some of the products of conception are
expelled; most often the placenta is not
expelled; bleeding is heavy and cramping is
severe.
o Complete
 All products of conception are expelled.
o Missed
  Embryo or fetus dies but is retained; the
cervix is closed; if the fetus is not expelled
within 6 weeks, disseminated intravascular
coagulation may develop.
o Habitual
 Any of the above occurring in 3 consecutive
pregnancies; most commonly the cervix
begins to dilate in the 2nd trimester; this is
called an incompetent cervix.
o Management
 Limit activities for 24 – 48 hours
 Avoid stress, fatigue, strenuous activity and sexual intercourse if
bleeding stops.
 Increase rest periods until pregnancy seems to be progressing
normally.
 Dilatation and curettage or suction evacuation is performed to
remove the products of conception from the uterus for inevitable
or incomplete abortion.
 Blood transfusion may be given depending on the amount of
blood loss.
 Induction of labor for missed abortion in 12 weeks AOG and D&C
for less 12 weeks AOG and below.
 Cerclage for habitual abortion caused by incompetent cervix.
(Shirodkar) Procedure suture material is placed on the cervix in a
purse string fashion at the level of the internal os done about 16
weeks AOG.
o Nursing Considerations
 Prevention or identification of hypovolemic shock
• Tachycardia
• Falling BP
• Pale skin and mucous membranes
• Confusion
• Restlessness
• Cool, clammy skin.
 Emphasize that spontaneous abortion usually occur because of
factors or abnormalities that could be avoided.
 Provide emotional support.
 Recognize the meaning of the loss to each family member.
 Provide information with brief and simple explanation.
• Ectopic Pregnancy
o Implantation of a fertilized ovum in an area outside the uterus cavity.
o Ampulla of fallopian tube (90%)
o “A disaster of reproduction”
 Leading cause of maternal mortality due to hemorrhage.
 Reduces the chance for woman for subsequent pregnancy.
o Risk factors
 History of STIs, PID, previous ectopic pregnancy
 Failed tubal ligation
 IUD
 Multiple induced abortion
 Maternal age: > 35 years old
o Clinical manifestation
  Missed menstrual period
 Abdominal and pelvic pain
 Vaginal spotting or light bleeding
 Profuse hemorrhage
 Signs of hypovolemic shock
o Diagnostics
 Transvaginal UTZ
 Serum hormone level
• Progesterone
• HCG
 Culdocentesis – insertion of needle to upper posterior part of the
vaginal wall to aspirate pelvic fluid.
 laparoscopy
o Management
 Methotrexate
• Explain adverse side effects.
• Instruct to refrain from alcohol and folic acid
• Avoid sexual intercourse.
• Emphasize follow – up appointments
 Linear salphingotomy
• Incision along the fallopian tube
• No suture to the opening to prevent scarring.
 Salphingectomy
• Hydatidiform Mole
o Gestational trophoblastic disease
o Proliferation and degeneration of the trophoblast villi where the
fertilized ovum dies and the chorion develops into vesicles (grape – like
clusters).
o Choriocarcinoma, possible infection.
o Types:
 Complete
• All trophoblastic villi swell and become cystic
• Has only paternal genetic material
• No fetus present
 Partial
• Some of the villi form normally
• There is a fetus with multiple chromosomal …
o Clinical Manifestations
 Elevated HCG
 Vaginal bleeding (dark brown spotting to profuse hemorrhage)
 Uterus larger than expected for the duration of the pregnancy.
 No FHT
 Excessive nausea and vomiting due to increased HCG
 Early development of PIH – occur 24 weeks after AOG
o Diagnostic
 Ultrasound
o Management
 Immediate evacuation of the mole
 Vacuum aspiration followed by curettage
 Pre
• Chest radiography, CT scan or MRI
 • CBC, blood typing and cross matching.
 Post
• IV oxytocin
 Follow up to detect malignant changes in the remaining
trophoblastic tissue.
• Placenta Previa
o Implantation of the placenta in the lower uterine segment in advance
of the fetal presenting part.
o Types:
 Complete – placenta completely covers the internal os
 Partial – partially covers the internal os.
 Marginal – placenta just reaches the internal os but doesn’t cover
it.
 Low – lying placenta – extends into the lower uterine segment but
doesn’t reach the internal os.
o Clinical Manifestation
 Spotting
 Painless uterine bleeding
o Diagnostics
 Transabdominal sonography
 Transvaginal sonography
o Precautions
 No IE; DRE; oxytocin
o Management
 Aim: maintain the pregnancy until the fetus is mature enough to
survive outside the uterus.
 Conservative Management
• Home care
o Criteria
 Client is stable with no evidence of active
bleeding.
 Client can remain on bed rest at home
 Home is within reasonable distance from the
hospital.
 Emergency transportation is available 24
hours a day.
• Inpatient care
o Manage patient in the hospital
 FHR monitored as well as bleeding.
 Fetal activity.
 Cesarian Birth
• Factors
o > 36 weeks AOG
o Excessive bleeding
o Unstable cardiovascular status
o Signs of fetal compromise
 Betamethasone (celestone)
• Accelerates lung maturation
o Nursing Considerations
 Monitor bleeding
 Bed rest with O2 as prescribed
 Positioning: side lying or trendelenburg
  Monitor fetal status
 Keep IV line and make blood available.
• Abruptio Placenta
o Premature separation from the wall of the uterus of a normally
implanted placenta.
o Occurs spontaneously after the 20th week of gestation in 1 out of 75 –
90 pregnancies.
o Types:
 Central AP
• Center of the placenta separates with blood trapped
between placenta and the uterine wall.
• No apparent bleeding
 Marginal AP
• Edge of placenta separates with profuse bleeding
apparently vaginally.
 Complete AP
• Entire placenta separate with profuse bleeding apparent
vaginally.
o Contributory Factors
 Trauma
 Short umbilical cord or uterine anomaly
 Maternal hypertension
 Multiple pregnancy
 Smoking
 Use of alcohol or cocaine
o Clinical Manifestation
 Vaginal bleeding
 Tender and painful abdomen (board like)
 Couvelaire uterus
o Complication
 Pre term labor
 Anemia
 Irreversible brain damage
 Fetal death
o Diagnostic
 Ultrasound
o Management
 Aim: rational plan for delivery of the fetus
 Intravenous fluid (LRS)
 Induction of labor if the separation is small and pregnancy is near
term.
 Amniotomy
 Caesarian birth is performed if labor is not progressing in 8 hours.
 Tocolytic medication (ritodrine[Yutopar])
 Bed rest until situation is stable
• Vasa Previa
o Refers to fetal vessels running through the membranes over the cervix
and under the fetal presenting part unprotected by placenta or
umbilical cord.
• Placenta Accreta
o Any placental implantation in which there is abnormally firm adherence
to the uterine wall.
 o Types:
 Placenta increta – myometrium
 Placenta percreta – surpass the myometrium
 Total PA – all cotyledons are attached to the myometrium
 Partial PA – some cotyledons are attached to the myometrium
 Focal PA – only one cotyledon is attached to the myometrium
• *asherman’s syndrome – adhesion after CS
• Hysterectomy; hysteroscopy + adhesiolysis
• Hyperemesis Gravidarum
o Persistent uncontrollable vomiting during pregnancies.
o Excessive vomiting of pregnant women
o Causative Factors
 Hormonal changes
• Increased HCG, estrogen and progesterone [delay GIT
motility]levels (salivation)
• Psychological factors
 Complications
• Weight loss
• Dehydration
• Vitamin deficiency
 Diagnostic
• Laboratory studies (HGB & HCT; serum electrolytes)
 Management
• IV rehydration
• TPN as necessary
• Antiemetic drugs
 Nursing considerations
• Reducing nausea and vomiting
o Dry crackers or toast
o Rise slowly from bed
o Small frequent feeding
o Drink fluids in between meals
o Avoid greasy or spicy foods
• Maintaining nutrition and fluid balance
o IVF and TPN as directed
o Increase K and Mg intake
o Clear fluids are started as N&V subside.
• Providing emotional support
• Disseminated Intravascular Coagulation
o Over stimulation of the normal clotting process
o Rapid massive fibrin formation causes small thrombi to form
throughout the circulatory system depleting the clotting factors and
platelets.
o Causative factors:
 Premature separation of the placenta
 PIH
 Placental retention
 Amniotic fluid embolism
 Septic abortion
 Dead fetus retention
o Clinical Manifestation
  Bruising or bleeding from the IV site
 Dyspnea / chest pain
 Restlessness
 Cyanosis
 Frothy, blood – tinged mucous
o Diagnostics
 HGB
 HCT
 Fibrinogen level
 Prothrombin time
 Partial thromboplastin time
o Management
 Facilitate delivery if the fetus is not yet born
 Administration of blood fibrinogens
 Continuous administration of heparin
 Oxygen therapy
• Pregnancy Induced Hypertension
o Multiorgan disease process that develops during pregnancy and
regresses in the post partum period
o Most common hypertension disorder in pregnancy
o Appears after 20 weeks of gestation
o Risk factors:
 Primigravida
• In lower socio-economic group
• With poor nutritional status
 Mother with history of
• Diabetes
• Multiple pregnancy
• PIH
o Clinical Manifestation
 Hypertension
 Edema
 Proteinuria
o Classification
 Gestational Hypertension
• Elevated BP of 140/90 mmHg
• No proteinuria or edema
• No drug therapy is necessary
 Mild Pre – eclampsia
• BP: increase 30 mmHg (systole)/ increase 15 mmHg
(diastole) over the client’s baseline BP on 2 occasions at
least 6 hours apart.
• Edema may be noted in the face and hand
• May show 1+ or 2+ albumin on a dipstick or 300 mg / L in
24 hours.
 Severe pre – eclampsia
• BP increases 160/110 mmHg or higher on 2 occasions of 6
hours apart.
• Generalized edema on the face, hands sacral area, lower
extremities or abdomen.
• Urinary albumin is 3+ or 4+ in a dipstick
 • Urine output may drop to lower than 500 mL / 24 hours.
• Elevated hematocrit, uric acid and serum creatinine levels
• Other clinical manifestations
o Continuous headache
o Scotomata (spots before the eyes)
o N and V
o Irritability
o Hyper reflexia
o Cerebral disturbances
o Pulmonary edema
o Epigastric pain (last symptom identified before the
client moves into eclampsia.
 Eclampsia
• Grand mal seizures with tonic (pronounced muscular
contraction) and clonic (alternate contraction and
relaxation of muscle) phase.
• A client sleeps into a coma from minutes to hours.
• Seizures/coma sequence can be repeated one or more
time and death may follow.
o Chvostek’s sign
o Trousseau’s sign
 HELLP syndrome
• PIH with liver damage
• Characterized by HELLP
o Hemolysis is caused when intra-arterial lesions
develop due to vasospasm causing platelets to
aggregate and a fibrin network to be formed; the
RBC are forced through the fibrin network and lysis
resulting in large drop in hematocrit.
o Elevated liver enzymes may be due to microemboli
in the vessels of the liver causing ischemia
o Low platelet counts result when the platelets are
entrapped at the intra-arterial lesions
o Results to ischemia and tissue damage
o May show signs of hypoglycemia.
• Management
o Goal: lowers BP, prevent convulsion and deliver a
healthy baby
o Complete bed rest for client’s mild preeclampsia
with increase renal and placental blood flow.
o Monitor laboratory data
o Caesarian birth
o MgSO4
o Hydralazine
o Sedative may be given to let the client rest quietly
o Oxytocin may be given to induce labor
• Gestational Diabetes Mellitus
o General Information
 Chronic disease caused by improper metabolic interaction of
carbohydrates, protein, fats and insulin
 Interaction of pregnancy and diabetes may cause serious
complications of pregnancy
 Classifications of Diabetes mellitus:
 • Type 1: formerly called juvenile-onset or insulin-
dependent diabetes; onset before age 40
• Type 2: formerly called maturity-onset or non-insulin-
dependent; onset after age 40
• Type 3: formerly called gestational; onset during
pregnancy; reversal after termination of pregnancy
• Type 4: formerly called secondary; occurs after pancreatic
infections or endocrine disorder
o Significance of Diabetes in pregnancy
 Interaction of estrogen, progesterone, HPL and cortisol raise
maternal resistance to insulin (inability to use glucose at the
cellular level).
 If the pancreas cannot respond by producing additional insulin,
excess glucose moves across placenta to fetus, where fetal
insulin metabolizes it and acts as growth hormone, promoting
macrosomia.
 Maternal insulin levels need to be carefully monitored during
pregnancy to avoid widely fluctuating levels of blood glucose.
 Dose may drop during first trimester, then rise during second and
third trimesters.
 Higher incidence of fetal anomalies and neonatal hypoglycemia
(good control minimizes)
o Assessment Findings
 Polyuria
 Polydipsia
 Weight loss
 Polyphagia
 Elevated glucose levels in blood and urine. Urine tests for
elevated blood glucose less reliable in pregnancy. Blood tests
(more accurate) used as follows:
• 1-hour glucose tolerance test: usually done for screening
on all pregnant women 24-28 weeks pregnant.
• 3-hour glucose tolerance test: used where results from
1hour GTT> 140 mg/dl.
• HbAlc: glycosylated hemoglobin; reflects past
 4-12 week blood levels of serum glucose.
o Nursing Interventions
 Teach client the effects and interactions of diabetes and
pregnancy and signs of hyper- and hypoglycemia
 Teach client how to control diabetes in pregnancy, advice of
changes that need to be made in nutrition and activity patterns
to promote normal glucose levels & prevent complications.
 Advice client of increased risk of infection and how to avoid it.
 Observe and report any signs of preeclampsia
 Monitor fetal status throughout pregnancy
 Assess status of mother and baby frequently
 Monitor carefully fluids; calories, glucose and insulin during labor
and delivery
 Continue careful observation in post delivery.
• Rh incompatibility
B. Intrapartal Period
• Extends from the beginning of contractions that causes cervical dilatation to the
1st 4 hours after delivery of the newborn and placenta.
• Labor
o Process by which the fetus and products of conception are expelled as the
result of regular, progressive, frequent, strong uterine contractions.
o Theories Explaining Onset Of Labor
 Uterine Stretch Theory
• A hollow organ such as the uterus when full will empty.
 Oxytocin Theory
• Oxytocin released by the posterior pituitary gland initiates
labor.
 Progesterone Deprivation Theory
• Contraction initiated when progesterone level are decreased
as such at the end of pregnancy.
 Prostaglandin Cascade Theory
• Labor is initiated due to the production of prostaglandin as a
result of interplay between adrenal, fetus and uterus.
 Aging Placenta Theory
o Components of Labor and Delivery
 Power
• Forces that cause the cervix to open and propel the fetus
through the birth canal.
• Uterine contraction
o Primary power of labor
o Characteristics
 Involuntary contraction
• Spontaneous contraction
• Cervix dilatation and effacement of the
cervix during the 1st stage of labor
• Phases: Increment (gain strength). Acme
(peak), Decrement (letting go)
 Intermittent Contraction
• Description
o Frequency
o Duration
o Intensity
o Regularity
• Maternal Push
o Voluntary beating down efforts
o After full dilatation of the cervix
o Efforts similar to those of defecation
o Contraction of levator ani muscle
 Passenger
• Refers to the fetus plus the membranes and placenta
• Fetal skull and fetal accommodation to passageway affects
the labor progress.
• Indication of fetal head
o Largest part of the body
o Common presenting part
o Least compressible fetal part
 Cranial bones
• Frontal – 1
• Parietal – 2
• Temporal – 2
 • Occipital – 1
• Sphenoid – 1
• Ethmoid - 1
• Suture line
o Intermembranous spores
o Allows molding – overlapping of the sutures
o Sagittal – 2 parietal
o Coronal – parietal and frontal
o Lamboidal – parietal and occipital
• Fontanels
o Anterior fontanel
 4 cm in any direction – normal size
 Diamond in shape
 Closes at 12 – 18 months
o Posterior fontanel
 < 1 cm – normal size/location
 Triangular in shape
 Closes 2 – 3 months
• Measurements
o Transverse diameter
 Biparietal – largest at 9.5 cm
 Bitemporal – 8 cm
 Bimastoid – smallest at 7 cm
o Antero-posterior diameter
 Sub-occipito bregmatic – 9.5 cm
 Occipito – frontal – 12 cm
 Occipito – mental – 13.5 cm
 Submento bregmatic – face presentation
• Fetal Accommodation to the Passageway
o Fetal Lie
 Transverse
 Longitudinal
 Oblique
o Presentation
 Cephalic
• Vertex – head is completely flexed, chin
touching chest
• Sinciput – anterior fontanel is the
presenting part
• Brow – head is bent back causing the
occipitomental diameter
• Face presentation
• Chin presentation
 Breech / buttock / lower extremities
presentation
• Frank - thighs flexed, legs extended on
anterior body surface, buttocks
presenting
• Full or complete – squatting presentation
• Footling – one or both
 Shoulder / horizontal / transverse presentation
 Compound presentation
 • Presentation occurs when there is
prolapsed of the fetal head alongside the
vertex, breech or shoulder.
o Position
 Relationship of the landmark on the presenting
part to the front, side, and back of the maternal
pelvis.
 Maternal side 1st – refer to the side of the
maternal pelvis in which the part is found right
or left.
• Fetal presentation side
o Occiput (O) – vertex or military
o Frontum/ brow (FR) – brow
o Mentum / chin (M) – face
o Sacrum (S) – breech
o Scapula (Sc) - shoulder
 Maternal quadrant
• Side of the maternal pelvis which the
reference point is found.
• Anterior – front of the pelvis
• Posterior – back
• Transverse - side
 Most common positions
• LOA – favorable delivery position
o Facing the lower left abdomen
• ROA – fetal occiput on maternal side
• LOP – maternal side and toward back,
face is up
o Labor is slowed and much back
discomfort on mother during labor.
• ROT – occiput is facing the right side and
looking toward the left side.
o Attitude or Habitus
 Describes the degree of flexion a fetus assume
during labor or the relationship of fetal part to
each other
 Full flexion (Vertex) – good attitude – normal
fetal position
• Presents the smallest anterior diameter
 Moderate flexion (sinciput)
 Chin not touching the chest (military)
 Partial extension (Brow) – brow of head to the
birth canal
 Complete extension (face)
o Station
 Descent of the fetal presenting part in
relationship to the level of the ischial spine
 0 – level of ischial spine
 -3 to -1 – above the ischial spine
 +1 to +3 – below the ischial spine
o Engagement
  Settling of the presenting part of a fetus far
enough into the pelvis to determine the level of
ischial spine
 Passageway

• Maternal pelvis

o False pelvis – part of the bony passageway

o True pelvis

 Landmark: inlet (entrance to the midpelvis);

outlet (exit point)

 Measurements – estimate size of true pelvis

• Obstetric conjugate – smallest diameter

of the inlet where fetus must pass

o 1.5 – 2 – form diagonal conjugate

for approximation.

o 11 cm – adequate to accommodate
delivery

• Diagonal conjugate – distance from the

promontory of the sacrum to the lower.

• Pelvic shapes

o Android

o Anthropoid

o Gynaecoid

o Platypeloid

 Psyche

• Physical preparation of childbirth

• Three Categories

o Psychophysical

 Bradley’s method – presence of husband

 Dick Read method – fear produces tension, pain

o Psychosexual
  Ketzinger’s method – states that pregnancy,
labor, birth, and care of newborn are an
important turning point in woman’s cycle.

o Psychoprophylactic

 Lamaze – requires discipline, conditioning and

concentration

 Prevention of pain

• Features:

o Conscious relaxation

o Cleansing birth inhaling to the nose

and mouth exhaling

o Effleurage – light abdominal

massage

• Cultural heritage

• Previous experience – complication of delivery and mode of

birth outcome

o Methods of Delivery
 Birthing chair – semifowler position
 Birthing bed – dorsal recumbent
 Squatting position – relieves local pain and facilitate descent
 Leboyer’s method – quiet and calm environment, soft music, dark
lighted room
 Birth under water
o Signs of Labor and Delivery
 Culmination of pregnancy but the beginning of parenting.
 Pre – eminent signs of labor
• Lightening / engagement
o Presenting part of the fetus descends to pelvic brim
• Weight loss
o Decreased 2 – 3 pounds around 1 – 2 days before
onset of labor
• Increased activity level
• Increased Braxton hick’s contraction
• Diarrhea – result of increases nerve enervation due to
descent
• Ripening of cervix
• Bloody show – 1st sign
o Mixture of thick mucous and pink or dark brown blood.
o Pink – tinged mucus vaginal discharge
• Rupture of membranes
o There is danger of cord prolapsed if fetal head is not
engaged and serious infection.
 oLabor and delivery will most probably occur within 24
hours
 Nursing Management
• Assess FHR for 1 full minute
• Assess color of amniotic fluid
o Normal: clear or straw colored with specs of vernix
caseosa
o Green – tinged: fetal distress
o Yellow colored: hemolytic disease, hyperbilirubinemia
o Gray or cloudy: infection
o Pinkish/ red stained: bleeding
o Brownish/ tea colored/ coffee colored – fetal death.
• Record time and rupture, characteristics of fluid and FHR
TRUE FALSE
Contraction Regular Irregular
Increase frequency, No change in
duration and frequency, duration
intensity and intensity
Shortening of
interval
Discomfort Radiates from back Pain at the abdomen
Around the abdomen
Rest and Activity Contraction does not Contraction may
decrease with rest or lessen with activity
activity/ walking or rest
Cervix Progressive Cervical changes do
effacement and not occur.
dilatation of cervix
o Danger Signs of Pregnancy
Signs Possible cause
Swelling of face, finger, legs PIH, thrombophlebitis (Leg)
Headache, continuous and PIH
severe
Abdominal / chest pain Ectopic, uterine rupture,
pulmonary embolism
Vaginal bleeding Placental problems
Vomiting, persistent Infection (also with fever and
chills), hyperemesis gravidarum
Visual changes PIH
Escape of vaginal fluids PROM

o Progress of Labor
o Engagement, Descent and Flexion
o Internal Rotation
o Extension
 Extension complete (delivery of fetal head)
 Aspiration of mouth
o External rotation
 Delivery of shoulder
o Expulsion
o Stages of Labor
Phases Dilatation Duration Intensity
 I (Latent) 0 – 3 cm 10 – 30 sec Mild to
5 – 30 min moderate
1st Stage II (Active) 4 – 7 cm 30 – 40 sec Moderate to
3 – 5 min severe
III 8 – 10 cm 45 – 90 sec Severe
(Transition) 2 – 3 min

Phases Dilatation Contraction

2nd Stage
I 0 - +2 2 -3 min
apart
II +2 - +4 2 – 2.5 min
apart with
urgency to
bear down
III +4 - birth 1 – 2 min
apart, fetal
head visible
with
increased
urgency to
bear down

3rd Stage Placental delivery

-
Sudden gush of blood, lengthening of the cord,
rising of the fundus, globular uterus
4th Stage 1st 4 hours after delivery of the placenta (v/s, fundus and
lochia monitoring every 15 minutes until stable.)
o Nursing Considerations
o Monitor v/s, FHR
o Provide comfort measures
 Ambulation
 Side lying position
 Sacral pressure
 Back rubs
o Breathing technique during transition phase
o Evaluate placental completeness
o Complications of Labor and Delivery
o Preterm Labor
 Begins after the 20th week but before the end of 37th week of
pregnancy.
 Biochemical markers
• Fetal fibronectins – glycoprotein found in the plasma
(vaginal swab test).
• Salivary estriol – form of estrogen (salivary swab test).
 Risk factors
• Previous preterm labor
• Abdominal surgery
• Younger than 18 years old
• Older than 40 years old
• Low socio – economic class
• Abnormality of fetus or placenta
 • Multiple gestation
• Emotional and physical stress
• Nutritional deficiency
 Clinical Manifestations
• Uterine contractions (painful/less)
• Abdominal cramps (menstrual cramps; with/out
diarrhea)
• Constant low back ache
• Sensation of pelvic pressure
• Change or increase in vaginal discharge
• A sense of “just feeling bad” or “coming down with
something”.
 Management
• Focus: prevention of delivery of premature fetus.
• Identify and treating infections – UTI
• Restricting activity – left side lying position (increasing
placental blood flow, prevent hypotension; decrease
fetal pressure on the cervix).
• Hydrating the woman
• Tocolytic therapy
o Ritodrine (Yutopar)
o Terbutaline (Brethine)
o MgSO4 – anti – convulsant
o Prostaglandin synthesis inhibitor
• Accelerating fetal lung maturity
o Corticosteroid – within 24 hours, it will be
effective
 Betamethasone
 dexamethasone
o Premature Rupture of Membranes
 Rupture of the amniotic sac before the onset of true labor,
regardless of length of gestation.
 Preterm Premature Rupture of Membranes
• Earlier than end of 37th week
 Causative Factors
• Vaginal or cervical infections – gonorrhea
• Chorioamnionitis
• Incompetent cervix
• Fetal abnormalities or malpresentation
• Hydramnios
• Amniotic sac with a weak structure
• Recent sexual intercourse
• Nutritional deficiencies
 Management
• Prevent complications
• Oxytocin induction or caesarean birth
 Nursing considerations
• No coitus or douching
• Avoid breast stimulation
• Monitor temperature (> 37.8 degrees celcius)
• Maintain bed rest (50 % effective)
o Precipitate Labor
 Precipitous labor
 Labor that lasts less than 3 hours from the onset of
contraction to the time of birth.
 Occur when uterine contraction are so strong that the woman
given birth wit only a few rapid occurring contractions.
 Tetanic intensity of contractions
 Complications
• Mother
o Uterus rupture
o Laceration of the birth canal
o Post partum hemorrhage
• Fetus
o Hypoxia (brain) – caused by decreases periods
of uterine relaxation.
o Subdural hemorrhage – due to rapid birth
 Induction and Augmentation of Labor
• Use of artificial method to stimulate uterine
contractions
• Indications
o PIH
o Spontaneous ROM at or near term without labor
o Chorioamnionitis
o Maternal medical conditions that are worsening
with continuation of pregnancy (DM, pulmonary
diseases)
o Conditions in which the intrauterine
environment is hostile to fetal well – being.
• Pre – induction
o Fetus is longitudinal lie
o Cervix is ripe/ ready for birth
o A presenting part is engaged
o No CPD
o Fetus is estimated to mature by date (L/S ratio
or sonogram)
 Scoring of effacement of cervix
• Techniques / methods
o Amniotomy
 Artificial rupturing of membranes using
amniotomy forceps (allis, amnihook –
perforator)
 Indications
• To reduce or augment labor
• To perform internal fetal monitor
• To determine color of amniotic fluid
when fetal compromise is
suspected.
• To prevent aspiration of the
contents of the amniotic sac at the
moment of birth
 Nursing Considerations
• NPO before amniotomy
 • Ascertain fetal lie, position and
presentation (UTZ, palpitation)
• Explain the procedure
• Immediately after the rupture,
check FHR
• Note color, amount of amniotic
fluid
• Note time of rupture (prevent dry
labor and infection).
o Oxytocin Administration
 Average: 10 – 20 units
 Maximum: 80 units
 Precautions:
• Diluted in a physiologic electrolyte
containing fluid and given as
secondary (piggyback) infusion.(to
easily stop when there is
hypertonic contractions.)
• Started slowly, increased gradually
and regulated with an infusion
pump
• Monitor uterine activities and FHR.
o Dystocia
 Prolonged and difficult labor
 Also known as
• Difficult labor / childbirth
• Abnormal labor / childbirth
• Dysfunctional labor
 Types:
• Uterine dysfunction
o Abnormalities of the powers
 Hypotonic uterine dysfunction
 Hypertonic uterine dysfunction
 Inadequate secondary force
• Abnormalities with the passageway
o Pelvic dystocia
 Inlet; midpelvis, outlet dystocia
o Soft tissue dystocia
 Placenta previa
 Tumors that distend the birth canal
o Fetal dystocia; abnormalities of the passenger
 Malposition
 Breech presentation
 Face presentation
 Brow presentation
 Shoulder presentation
 Multiple presentation
 Macrosomia (large babies)
 Hydrocephalus
o Uterine rupture
 Tear in the wall of the uterus that occurs because it cannot
withstand the pressure against it.
  Variations
• Complete – includes broad ligament and the peritoneal
cavity.
o Sudden excruciating pain at the peak of
contraction.
• Incomplete – the broad ligament is included but not
the peritoneal cavity
o Localized tenderness and persistent pain on the
abdomen.
• Dehiscence – partial separation of an old uterine scar
 Clinical Manifestation
• Abdominal pain and tenderness
• Chest pain between the scapula or on inspiration
• Hypovolemic shock after birth
• Signs associated with impaired fetal oxygenation
(bradycardia, delayed deceleration).
• Absent FHT
• Cessation of uterine contraction
• Palpation of fetus outside the uterus
 Management
• Stabilize the woman and fetus
• Perform cesarian delivery
• Hysterectomy
o Considerations: consent from both parents and
age factor.
 Nursing Considerations
• Infuse BT and IVF as ordered
• Administer oxytocin cautiously
• Monitor for hypertonic contractions and notify
physician.
• Post – op
o Avoid driving (3 - 6 weeks)
o Avoid jogging, sexual intercourse, dancing,
lifting heavy objects (6 – 8 weeks)
o Prolapsed Umbilical Cord
 Occurs when the cord passes out of the uterus ahead of the
presenting part.
 Risk factors
• Fetus that remains at a high station
• A very small fetus
• Breech presentation
• Transverse lie
• Hydramnios
• Long cord
• Placenta previa
 Clinical Manifestation
• Completer prolapse – visible on the vulva
• Occult prolapse – cord slips alongside with the head or
shoulder of fetus
• Changes in FHR (bradycardia)
 Management
 • Focus: to relieve pressure on the cord to restore blood
flow through it until delivery.
• Position the woman hip higher than her head to shift
the fetal presenting part toward her diaphragm.
o Knee chest
o Trendelenburg
o Hips elevated with pillows, with side lying
position maintained.
• With gloved hand, push the fetal presenting part
upward.
• Oxygenation at 8 – 10 LPM via face mask.
• Tocolytic drug, terbutaline (inhibit contraction; increase
placental blood flow)
• Warm saline – moistened towels retard cooling and
drying of cord.
 Nursing considerations
• The nurse must remain calm and acknowledge the
woman’s anxiety.
• Simple explanation of the condition.
• Include the family (decision making).