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MATERNAL/OB NOTES
Human Sexuality A. Concepts 1. A persons sexuality encompasses the complex behaviors, attitudes emotions and preferences that are related to sexual self and eroticism. 2. Sex basic and dynamic aspect of life 3. Durin reproductive years, the nurse performs as resource person on human sexuality. B. Definitions elate! to sexuality" !ender identity sense of femininity or masculinity 2"# yrs$3 yrs ender identity develops. %ole identity attitudes, behaviors and attributes that differentiate roles Sex biolo ic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse. Sexuality " behavior of bein boy or irl, male or female man$ &oman. 'ntity life lon dynamic chan e. " developed at the moment of conception. ##. Sexual Anatomy an! $%ysiolo&y A. 'emale Rep o!ucti(e System 1. 'xternal value or pretender a. Mons pu)is/(ene is " a pad of fatty tissues that lies over the symphysis pubis covered by s(in and at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis. Sta&es of $u)ic Hai De(elopment )annerscale tool " used to determine sexual maturity ratin . Sta e 1 *re"adolescence. +o pubic hair. ,ine body hair only Sta e 2 -ccurs bet&een a es 11 and 12 sparse, lon , sli htly pi mented . curly hair at pubis symphysis Sta e 3 occurs bet&een a es 12 and 13 dar(er . curlier at labia Sta e # occurs bet&een a es 13 and 1#, hair assumes the normal appearance of an adult but is not so thic( and does no appear to the inner aspect of the upper thi h. Sta e / sexual maturity" normal adult" appear inner aspect of upper thi h . ). La)ia Ma*o a " lar e lips lon itudinal fold, extends symphisis pubis to perineum c. La)ia Mino a 2 sensitive structures clitoris" anterior, pea shaped erectile tissue &ith lots sensitive nerve endin s si ht of sexual arousal 0!ree("(ey1 fourchette" *osterior, tapers posteriorly of the labia minora" sensitive to manipulation, torn durin delivery. Site episiotomy. !. +esti)ule an almond shaped area that contains the hymen, va inal orifice and bartholenes lands. 2rinary 3eatus small openin of urethra, serves for urination S(enes lands$or paraurethral land mucus secretin subs for lubrication hymen covers va inal orifice, membranous tissue va inal orifice external openin of va ina bartholenes lands" parava inal land or vulvo va inal land "2 small mucus secretin subs secrets al(aline subs. Al(aline neutrali4es acidity of va ina *h of va ina " acidic Doderleins bacillus responsible for acidity of va ina 5arumculae mystiformes"healin of torn hymen e. $e ineum , muscular structure loc lo&er va ina . anus 6nternal7 A. (a&ina female or an of copulation, passa e&ay of mens . fetus, 3 #inches or 8 19 cm lon , dilated canal %u ae permits stretchin &ithout tearin B. ute us- -r an of mens is a hollo&, thic( &alled muscular or an. 6t varies in si4e, shape and &ei hts. Si4e" 1x2x3 Shape7 nonpre nant pear shaped $ pre nant " ovoid :ei ht " nonpre nant /9 ";9 ( " pre nant 1,999 *re nant$ 6nvolution of uterus7 #th sta e of labor " 1999 2 &ee(s after delivery " /99 3 &ee(s after delivery " 399 /"; &ee(s after delivery " returns to ori inal, state /9 ;9 1. 2. 3. #. /.

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T% ee pa ts of t%e ute us 1. fundus " upper cylindrical layer 2. corpus$body " upper trian ular layer 3. cervix " lo&er cylindrical layer < 6sthmus lo&er uterine se ment durin pre nancy 5ornua"=unction bet&een fundus . interstitial Muscula compositions" there are three main muscle layers &hich ma(e expansion possible in every direction. 1. 'ndometrium" inside uterus, lines the nonpre nant uterus. 3uscle layer for menstruation. Slou hs durin menstruation. Decidua" thic( layer. 'ndometriosis"proliferation of endometrial linin outside uterus. 5ommon site7 ovary. S$sx7 dysmennorhea, lo& bac( pain. Dx7 biopsy, laparoscopy 3eds7 1. Dana4ole 0Danocrene1 a. to stop mens b. inhibit ovulation 2. >upreulide 0>upron1 inhibit ,S?$>? production 2. 3yometrium lar est part of the uterus, muscle layer for delivery process 6ts smooth muscles are considered to be the livin li ature of the body. " *o&er of labor, resp" contraction of the uterus 3. *erimetrium protects entire uterus C. o(a ies 2 female sex lands, almond shaped. 'xt" vestibule int ovaries ,unction7 1. ovulation 2. *roduction of hormones !. 'allopian tu)es 2"3 inches lon that serves as a passa e&ay of the sperm from the uterus to the ampulla or the passa e&ay of the mature ovum or fertili4ed ovum from the ampulla to the uterus. . si&nificant se&ments 1. 6nfundibulum distal part of ,), trumpet or funnel shaped, s&ollen at ovulation 2. Ampulla outer 3rd or 2nd half, site of fertili4ation 3. 6sthmus site of sterili4ation bilateral tubal li ation #. 6nterstitial site of ectopic pre nancy most dan erous B. Male Rep o!ucti(e System /. Exte nal penis the male or an of copulation and urination. 6t contains of a body of a shaft consistin of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female the lands penis. 0 Cylin! ical Laye s 2 corpora cavernosa 1 corpus spon iosum Sc otum a pouch han in belo& the pendulous penis, &ith a medial septum dividin into t&o sacs, each of &hich contains a testes. - coolin mechanism of testes " @ 2 de rees 5 than body temp. " >eydi cell release testosterone

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1. #nte nal T%e $ ocess of Spe mato&enesis , maturation of sperm

'lan() *an+t erase)

3estes 455 coiled 67 meter lon% at a%e 13 onwards# 6Seminiferous tubules#

,ypothalamus

Epididymis 6 meters coiled tubules site for maturation of sperm

-n.,
Vas Deferens conduit for spermatozoa or pathway of sperm

/nt &it -land

$S,

0$

Seminal esicle secretes! 1"# $ructose %lucose has nutritional alue" 2"# &rosta%landin causes re erse contraction of uterus E8aculatory duct conduit of semen

$1! Sperm 2aturation

$1! ,ormones for 3estosterone &roduction

&rostate %land- secrets al(aline substance *owpers %land secrets al(aline substance 9rethra

Male an! 'emale %omolo&ues Male *enile lans *enile shaft )estes *rostate 5o&pers !lands Scrotum 'emale 5litoral lans 5litorial shaft ovaries S(enes ands AartholinBs lands >abia 3a=ora

###. Basic 2no3le!&e on 4enetics an! O)stet ics 1. D+A carries enetic code 2. 5hromosomes threadli(e strands composed of hereditary material D+A 3. +ormal amount of e=aculated sperm 3 / cc., 1 tsp #. -vum is capable of bein fertili4ed &ith in 2# 3; hrs after ovulation /. Sperm is viable &ithin #8 C2 hrs, 2"3 days ;. %eproductive cells divides by the process of meiosis 0haploid1 Spermato enesis maturation of sperm -o enesis process " maturation of ovum !emato enesis formation of 2 haploid into diploid 23 D 23 E #; or diploid C. A e of %eproductivity 1/ ##yo

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8. 3enstruation" 3enstrual 5ycle be innin of mens to be innin of next mens Avera e 3enstrual 5ycle 28 days Avera e 3enstrual *eriod " 3 / days +ormal Alood loss /9cc or F cup %elated terminolo ies7 3enarche 1st mens Dysmenorrhea painful mens 3etrorrha ia bleedin bet&een mens 3enorha ia excessive durin mens Amenorrhea absence of mens 3enopause cessation of mens$ avera e 7 /1 years old G. ,unctions of 'stro en and *ro estin 5 Est o&en H?ormone of the :omanI *rimary function7 development secondary sexual characteristic female. -thers7 1. inhibit production of ,S? 0 maturation of ovum1 2. hypertrophy of myometrium 3. Spinnbar(eit . ,ernin 0 billin s method$ cervical1 #. development ductile structure of breast /. increase osteoblast activities of lon bones ;. increase in hei ht in female C. causes early closure of epiphysis of lon bones 8. causes sodium retention G. increase sexual desire <$ o&estin H ?ormone of the 3otherI *rimary function7 prepares endometrium for implantation of fertili4ed ovum ma(in it thic( . tortous 0t&isted1 Secondary ,unction7 uterine contractility 0favors pre nancy1 -thers7 1.inhibit prod of >? 0hormone for ovulation1 2.inhibit motility of !6) 3. mammary land development #. increase permeability of (idney to lactose . dextrose causin 0D1 su ar /. causes mood s&in s in moms ;. increase AA) /6. Menst ual Cycle # phases of 3enstrual 5ycle 1. *hases of 3enstrual 5ycle7 1. *roliferative 2. Secretory 3. 6schemic #. 3enses *arts of body responsible for mens7 1. hypothalamus 2. anterior pituitary land master cloc( of body 3. ovaries #. uterus 6nitial phase 3rd day decreased estro en 13th day pea( estro en, decrease pro esterone 1#th day 6ncrease estro en, increase pro esterone 1/th day Decrease estro en, increase pro esterone 6. -n the initial 3rd phase of menstruation , the estro en level is decreased, this level stimulates the hypothalamus to release !n%? or ,S?%, 66. !n%?$,S?%, stimulates the anterior pituitary land to release ,S? 'unctions of 'SH7 1. Stimulate ovaries to release estro en 2. ,acilitate ro&th primary follicle to become raffian follicle 0secrets lar e amt estro en . contains mature ovum.1 666. *roliferative *hase proliferation of tissue or follicular phase, post mens phase. *re"ovularoty. "phase of increase estro en. ,ollicular *hase causin irre ularities of mens *ostmenstrual *hase *reovulatory *hase phase increase estro en 6J. 13th day of menstruation, estro en level is pea( &hile the pro esterone level is do&n, these stimulates the hypothalamus to release !n%, on >?%, 1.1 3ittelschmer4 sli ht abdominal pain on > or %K of abdomen, mar(s ovulation day.

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2.1 5han e in AA), mood s&in !n%,$>?%, stimulates the ant pit land to release >?. 'unctions of LH7 1. 013th day"decreased pro esterone1 >? stimulates ovaries to release pro esterone 2. hormone for ovulation J6. 1#th day estro en level is increased &hile the pro esterone level is increased causin rupture of raffian follicle on process of ovulation. J66. 1/th day, after ovulation day, raafian follicle starts to de enerate yello&ish (no&n as corpus luteum 0secrets lar e amount of pro esterone1 J666. Secretory phase" >utheal *hase *ostovulatory *remenstrual J.

*hase 6ncreased pro esterone *hase

6L. 2#th day if no fertili4ation, corpus luteum de enerate 0 &hitish corpus albicans1 L. 28th day if no sperm in ovum endometrium be ins to slou h off to be in mens

,ornix" &here sperm is deposited Sperm" small head, lon tail, pearly &hite *honones"vibration of head of sperm to determine location of ovum Sperm should penetrate corona radiata and 4ona pellocida. 5apacitation" ability of sperm to release proteolytic en4yme to penetrate corona radiata and 4ona pellocida. //. Sta&es of Sexual Responses 0'*-%1 #nitial esponses" Jasocon estion con estion of blood vessels 3yotonia increase muscle tension 1. 'xcitement *hase 0si n present in both sexes, moderate increase in ?%, %%,A*, sex flush, nipple erection1 erotic stimuli cause increase sexual tension, lasts minutes to hours. 2. *lateau *hase 0accelerated J$S1 increasin . sustained tension nearin or asm. >asts 39 seconds 3 minutes. 3. -r asm 0involuntary spasm throu hout body, pea( v$s1 involuntary release of sexual tension &ith physiolo ic or psycholo ic release, immeasurable pea( of sexual experience. 3ay last 2 19 sec" most affected are is pelvic area. #. %esolution 0v$s return to normal, enitals return to pre"excitement phase1 Ref acto y $e io! the only period present in males, &herein he cannot be restimulated for about 19"1/ minutes A. 'e tili7ation B. Sta&es of 'etal 4 o3t% an! De(elopment 3"# days travel of 4y ote mitotic cell division be ins <*re"embryonic Sta e a. My ote" fertili4ed ovum. >ifespan of 4y ote from fertili4ation to 2 months b. 3orula mulberry"li(e ball &ith 1; /9 cells, # days free floatin . multiplication c. Alastocyst enlar in cells that forms a cavity that later becomes the embryo. Alastocyst coverin of blastocys that later becomes placenta . trophoblast d. 6mplantation$ +idation" occurs after fertili4ation C 19 days. ,etus" 2 months to birth. placenta previa implantation at lo& side of uterus Si ns of implantation7 1. sli ht pain 2. sli ht va inal spottin " if &ith fertili4ation corpus luteum continues to function . become source of estro en . pro esterone &hile placenta is not developed. 0 p ocesses of #mplantation 1. Apposition 2. Adhesion 3. 6nvasion C. Deci!ua thic(ened endometrium 0 >atin fallin off1 < Aasalis 0base1 part of endometrium located under fetus &here placenta is delivered < 5apsularies encapsulate the fetus

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< Jera remainin portion of endometrium. 5. C%o ionic +illi- 19 11th day, fin er life pro=ections 3 vesselsE A unoxy enated blood J -2 blood A unoxy enated blood :hartons =elly protects cord 5horionic villi samplin 05JS1 removal of tissue sample from the fetal portion of the developin placenta for enetic screenin . Done early in pre nancy. 5ommon complication fetal limb defect. 'x missin di its$toes. '. 5ytotrophoblast inner layer or lan hans layer protects fetus a ainst syphilis 2# &(s$; months life span of lan hans layer increase. Aefore 2# &ee(s critical, mi ht et infected syphilis ,. Synsitiotrophoblast synsitial layer responsible production of hormone 1. Amnion inner most layer a. 2mbilical 5ord" ,2+6S, &hitish rey, 1/ //cm, 29 21I. Short cord7 abruptio placenta or inverted uterus. >on cord7cord coil or cord prolapse b. Amniotic ,luid ba of ?2-, clear, odor mousy$musty, &ith crystalli4ed formin pattern, sli htly al(aline. 5'unction of Amniotic 'lui!" 1. cushions fetus a ainst sudden blo&s or trauma 2. facilitates musculo"s(eletal development 3. maintains temp #. prevent cord compression /. help in delivery process

normal amt of amniotic fluid /99 to 1999cc polyhydramnios, hydramnios" !6) malformation )',$)'A, increased amt of fluid oli ohydramnios" decrease amt of fluid (idney disease Dia&nostic Tests fo Amniotic 'lui! A. Amniocentesis empty bladder before performin the procedure. *urpose obtain a sample of amniotic fluid by insertin a needle throu h the abdomen into the amniotic sacN fluid is tested for7 1. !enetic screenin " maternal serum alpha feto"protein test 03SA,*1 1 st trimester 2. Determination of fetal maturity primarily by evaluatin factors indicative of lun maturity 3 rd trimester )estin time 3; &ee(s decreased 3SA,*E do&n syndrome increase 3SA,* E spina bifida or open neural tube defect 5ommon complication of amniocenthesis infection Dan erous complications spontaneous abortion 3rd trimester" pre term labor 6mportant factor to consider for amniocentesis" needle insertion site Aspiration of yello&ish amniotic fluid =aundice baby !reenish meconium A. Amnioscopy direct visuali4ation or exam to an intact fetal membrane. A. ,ern )est" determine if amniotic fluid has ruptured or not 0blue paper turns reen$ rey " D ruptured amniotic fluid1 5. +itra4ine *aper )est diff amniotic fluid . urine. *aper turns yello&" urine. *aper turns blue reen$ ray"0D1 rupture of amn fluid. 1. C%o ion &here placenta is developed >ecithin Sphin omyelin >$S %atio" 271 si nifies fetal lun maturity not capable for %DS Sha(e test amniotic D saline . sha(e ,oam test *hosphati lyceroli7 *!D definitive test to determine fetal lun maturity

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a. $lacenta 0Secundines1 !ree( panca(e, combination of chorionic villi D deciduas basalis. Si4e7 /99 or O ( "1 inch thic( . 8I diameter ,unctions of *lacenta7 1. %espiratory System be innin of lun function after birth of baby. Simple diffusion 2. !6) transport center, lucose transport is facilitated, diffusion more rapid from hi her to lo&er. 6f mom hypo lycemic, fetus hypo lycemic 3. 'xcretory System" artery " carries &aste products. >iver of mom detoxifies fetus. #. 5irculatin system achieved by selective osmosis /. 'ndocrine System produces hormones ?uman 5horionic !onadrophin maintains corpus luteum alive. ?uman placental >acto en or sommamommamotropin ?ormone for mammary land development. ?as a diabeto enic effect serves as insulin anta onist %elaxin ?ormone" causes softenin =oints . bones estro en pro estin

;. 6t serves as a protective barrier a ainst some microor anisms ?6J,?AJ ,etal Sta e H ,etal !ro&th and DevelopmentI 'ntire pre nancy days 2;; 289 days 3C #2 &ee(s Differentiation of *rimary !erm layers < 'ndoderm 1st &ee( endoderm primary erm layer )hyroid for basal metabolism *arathyroid " for calcium )hymus development of immunity >iver linin of upper %) . !6) < 3esoderm development of heart, musculos(eletal system, (idneys and repro or an < 'ctoderm development of brain, s(in and senses, hair, nails, mucus membrane or anus . mouth 'i st t imeste " 1st month " Arain . heart development !6). resp )ract remains as sin le tube 1. ,etal heart tone be ins heart is the oldest part of the body 2. 5+S develops di44iness of mom due to hypo lycemic effect ,ood of brain lucose complex 5?- pre nant &omans food 0potato1 Second 3onth 1. All vital or ans formed, placenta developed 2. 5orpus luteum source of estro en . pro esterone of infant life span end of 2 nd month 3. Sex or an formed #. 3econium is formed )hird 3onth 1. Pidneys functional 2. Auds of mil( teeth appear 3. ,etal heart tone heard Doppler 19 12 &ee(s #. Sex is distin uishable Secon! T imeste " ,-52S len th of fetus ,ourth 3onth 1. lanu o be ins to appear 2. fetal heart tone heard fetoscope, 18 29 &ee(s 3. buds of permanent teeth appear ,ifth 3onth 1. lanu o covers body 2. actively s&allo&s amniotic fluid

<

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3. 1G 2/ cm fetus, #. Kuic(enin " 1st fetal movement. 18" 29 &ee(s primi, 1;" 18 &(s multi /. fetal heart tone heard &ith or &ithout instrument Sixth 3onth 1. eyelids open 2. &rin(led s(in 3. vernix caseosa present T%i ! t imeste " *eriod of most rapid ro&th. ,-52S7 &ei ht of fetus Seventh 3onth development of surfactant lecithin 'i hth 3onth 1. lanu o be in to disappear 2. sub K fats deposit 3. +ails extend to fin ers +inth 3onth 1. lanu o . vernix caseosa completely disappear 2. Amniotic fluid decreases )enth 3onth bone ossification of fetal s(ull Te ato&ens- any dru , virus or irradiation, the exposure to such may cause dama e to the fetus A. Dru s7 Streptomycin anti )A . or Kuinine 0anti malaria1 dama e to 8 th cranial nerve poor hearin . deafness )etracycline stainin tooth enamel, inhibit ro&th of lon bone Jitamin P hemolysis 0destr of %A51, hyperbilirubenia or =aundice 6odides enlar ement of thyroid or oiter )halidomides Amelia or pocomelia, absence of extremities Steroids cleft lip or palate >ithium con enital malformation Alcohol lo&ered &ei ht 0vasoconstriction on mom1, fetal alcohol &ithdra&al syndrome char by microcephaly Smo(in lo& birth rate 5affeine lo& birth rate 5ocaine lo& birth rate, abruption placenta

A. 5. D. '.

TORCH 8Te ato&enic9 #nfections viruses 5?A%A5)'%6S)65S7 roup of infections caused by or anisms that can cross the placenta or ascend throu h birth canal and adversely affect fetal ro&th and development. )hese infections are often characteri4ed by va ue, influen4a li(e findin s, rashes and lesions, enlar ed lymph nodes, and =aundice 0hepatic involvement1. 6n some chases the infection may o unnoticed in the pre nant &oman yet have devastatin effects on the fetus. )-%5?7 )oxoplasmosis, -ther, %ubella, 5ytome alo virus, ?erpes simples virus. ) toxoplasmosis mom ta(es care of cats. ,eces of cat o to ra& ve etables or meat - others. ?epa A or infectious heap oral$ fecal 0hand &ashin 1 ?epa A, ?6J blood . body fluids Syphilis % rubella !erman measles con enital heart disease 01 st month1 normal rubella titer 1719 @1719 less immunity to rubella, after delivery, mom &ill be iven rubella vaccine. Dont et pre nant for 3 months. Jaccine is terato enic 5 cytome alo virus ? herpes simplex virus #. $%ysiolo&ical A!aptation of t%e Mot%e to $ e&nancy

A. Systemic C%an&es 1. Ca !io(ascula System increase blood volume of mom 0plasma blood1 39 /9Q E 1/99 cc of blood " easy fati ability, increase heart &or(load, sli ht hypertrophy of ventricles, epistaxis due to hyperemia of nasal membrane palpitation, *hysiolo ic Anemia pseudo anemia of pre nant &omen No mal +alues ?ct 32 #2Q

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? b C ite ia 1st and 3rd trimester." patholo ic anemia if lo&er ?5) should not be 33Q, ? b should not be @ 11 $d> 2nd trimester ?ct should not @32Q ? b ShdnBt @ 19./Q patholo ic anemia if lo&er $at%o&enic Anemia 6ron deficiency anemia is the most common hematolo ical disorder. 6t affects tou hly 29Q of pre nant &omen. Assessment reveals7 *allor, constipation Slo&ed capillary refill 5oncave fin ernails 0late si n of pro ressive anemia1 due to chronic physio hypoxia +ursin 5are7 +utritional instruction (an (on , liver due to ferridin content, reen leafy ve etable"alu bati,saluyot, malun ay, horseradish, ampalaya *arenteral 6ron 0 6mferon1 severe anemia, ive 63, M tract" if improperly administered, hematoma. -ral 6ron supplements 0ferrous sulfate 9.3 . 3 times a day1 empty stomach 1 hr before meals or 2 hrs after, blac( stool, constipation 3onitor for hemorrha e Alert7 6ron from red meats is better absorbed iron form other sources 6ron is better absorbed &hen ta(en &ith foods hi h in Jit 5 such as oran e =uice ?i her iron inta(e is recommended since circulatin blood volume is increased and heme is reRuired from production of %A5s 19./ 1# $d>

E!ema lo&er extremities due venous return is constricted due to lar e belly, elevate le s above hip level. +a icosities pressure of uterus - use support stoc(in s, avoid &earin (nee hi h soc(s - use elastic banda e lo&er to upper +ul)a (a icosities" painful, pressure on ravid uterus, to relieve" position side lyin &ith pillo& under hips or modified (nee chest position T% om)op%le)itis presence of thrombus at inflamed blood vessel - pre nant mom hyperfibrino enemia - increase fibrino en - increase clottin factor - thrombus formation candidate -utstandin si n 0D1 ?omanBs si n pain on cuff durin dorsiflexion 3il( le s(inny &hite le s due to stretchin of s(in caused by inflammation or phla masia albadolens 3 t7 1.1 2.1 3.1 #.1 /.1 ;.1 Aed rest +ever massa e Assess D ?oman si n once only mi ht dislod e thrombus !ive anticoa ulant to prevent additional clottin 0thrombolytics &ill dilute1 3onitor A*)) antidote for ?eparin toxicity, protamine sulfate Avoid aspirinS 3i ht a ravate bleedin .

2. Respi ato y system common problem S-A due to enlar ed uterus . increase -2 demand *osition" lateral expansion of lun s or side lyin position. 3. 4ast ointestinal 1st trimester chan e Mo nin& Sic:ness nausea . vomitin due to increase ?5!. 'at dry crac(ers or dry 5?- diet 39 minutes before arisin bed. +ausea afternoon " small freR feedin . Jomitin in pre emesis ravida. 3etabolic al(alosis, ,.' imbalance primary med m t replace fluids. 3onitor 6.-

constipation pro esterone resp for constipation. 6ncrease fluid inta(e, increase fiber diet

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" fruits papaya, pineapple, man o, &atermelon, cantaloupe, apple &ith s(in, suha. 'xcept uava has pectin thats constipatin ve petchy, malun ay. " exercise "mineral oil excretion of fat soluble vitamins 5 'latulence avoid as formin food cabba e < Hea t)u n or pyrosis reflux of stomach content to esopha us " small freRuent feedin , avoid 3 full meals, avoid fatty . spicy food, sips of mil(, proper body mechanical increase salivation ptyalsim m t mouth&ash <Hemo %oi!s pressure of ravid uterus. 3 tN hot sit4 bath for comfort #. ; ina y System freRuency durin 1st . 3rd trimester lateral expansion of lun s or side lyin pos m t for nocturia Acetyace test albumin in urine Aenedicts test su ar in urine <. Musculos:eletal >ordosis pride of pre nancy :addlin !ait a&(&ard &al(in due to relaxation causes softenin of =oints . bones *rone to accidental falls &ear lo& heeled shoes >e 5ramps causes7 prolon ed standin , over fati ue, 5a . phosphorous imbalance0T1 cause &hile pre nant1, chills, oversex, pressure of ravid uterus 0labor cramps1 at lumbo sacral nerve plexus 3 t7 6ncrease 5a diet"mil(06nc 5a . 6nc phosphorus1"1pint$day or 3"# servin s$day. 5heese, yo urt, head of fish, Dilis, sardines &ith bones, brocolli, seafood"tahon 0mussels1, lobster, crab. Jit D for increased 5a absorption dorsiflexion B. Local C%an&es >ocal chan e7 Ja ina7 J 5had&ic(s si n blue violet discoloration of va ina 5 !oodelBs si n chan e of consistency of cervix 6 ?e arBs chan e of consistency of isthmus 0lo&er uterine se ment1 >'2P-%%?'A &hitish ray, mousy odor dischar e 'S)%-!'+ hormone, resp for leucorrhea -*'%52>23 mucus plu to seal out bacteria. *%-!'S)'%-+' hormone responsible for operculum *%'!+A+) acidic to al(aline chan e to protect bacterial ro&th 0va initis1 $ o)lems Relate! to t%e C%an&e of +a&inal En(i onment" a. +a&initits trichomonas va inalis due to al(aline environment of va ina of pre nant mom ,la ellated proto4oa &ants al(aline S.Sx7 !reenish cream colored frothy irritatin ly itchy &ith foul smellin odor &ith va inal edema 3 t7 ,>A!U> 0metronida4ole antiproto4oa1. 5arcino enic dru so dont ive at 1 st trimester 1. treat dad also to prevent reinfection 2. no alcohol has antibuse effect JA!6+A> D-25?' 6K ?2- 7 1 tbsp &hite vine ar

b. Moniliasis o can!i!iasis due to candida albecans, fun al infection. 5olor &hite cheese li(e patches adheres to &alls of va ina. Si ns . Symptoms7 3ana ement antifun al +istatin, enshan violet, cotrimaxole, canesten !onorrhea ")hic( purulent dischar e Ja inal &arts" condifoma acuminata due to papilloma virus 3 t7 cauteri4ation

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2. Abdominal 5han es striae ravidarium 0stretch mar(s1 due enlar in uterus"destruction of sub K tissue avoid scratchin , use coconut oil, umbilicus is protrudin 3. S(in 5han es bro&n pi mentation nose chin, chee(s chloasma melasma due to increased melanocytes. Aro&n pin(ish line" linea ni ra" symphisis pubis to umbilicus #. Areast 5han es increase hormones, color of areola . nipple pre colostrums present by ; &ee(s, colostrums at 3rd trimester Areast self exam" C days after mens supine &ith pillo& at bac( Ruadrant A upper outer common site of cancer )est to determine breast cancer7 1. mammo raphy 3/ to #G yrs once every 1 to 2 yrs /9 yrs and above 1 x a yr ;. -varies rested durin pre nancy C. Si ns . symptoms of *re nancy A. $ esumpti(e s$s felt and observed by the mother but does not confirm positive dia nosis of pre nancy . Sub=ective A. $ o)a)le si ns observed by the members of health team. -b=ective 5. $ositi(e Si&ns undeniable si ns confirmed by the use of instrument. Aallotment si n of myoma < D ?5! si n of ? mole " trans va inal ultrasound. 'mpty bladder " ultrasound full bladder placental & a!in& ratin $ rade o immature 1 sli htly mature 2 moderately mature 3 placental maturity :hat is deposited in placenta &hich si nify maturity " there is calcium $ esumpti(e $ o)a)le Areast chan es !oodelBs" chan e of consistency of cervix 2rinary freR 5had&ic(s" blue violet discoloration of va ina ,ati ue ?e arBs" chan e of consistency of isthmus Amenorrhea 'levated AA) due to increased pro esterone 3ornin sic(ness *ositive ?5! or 0D1pre test 'nlar ed uterus Aallottement bouncin of fetus &hen lo&er uterine is 5loasma tapped sharply >inea ne ra 'nlar ed abdomen 6ncreased s(in Araxton ?ic(s contractions painless irre ular contractions pi mentation Striae ravidarium Kuic(enin

$ositi(e 2ltrasound evidence 0sono ram1 full bladder ,etal heart tone ,etal movement ,etal outline ,etal parts palpable

J6. $syc%olo&ical A!aptation to $ e&nancy 0'motional response of mom %eva %ubin theory1 ,irst )rimester7 +o tan inal si ns . sx, surprise, ambivalence, denial si n of maladaptation to pre nancy. Developmental tas( is to accept biolo ical facts of pre nancy ,ocus7 bodily chan es of pre , nutrition Second )rimester tan ible S.Sx. mom identifies fetus as a separate entity due to presence of Ruic(enin , fantasy. Developmental tas( accept ro&in fetus as baby to be nurtured. ?ealth teachin 7 ro&th . development of fetus. )hird )rimester7 " mom has personal identification on appearance of baby Development tas(7 prepare of birth . parentin of child. ?)7 responsible parenthood Vbabys >ayetteI best time to do shoppin . 3ost common fear let mom listen to ,?) to allay fear >ama4e classes +##. $ e-Natal +isit"

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1st C months 1x a month 8 G months 2 x a month 19 once a &ee( post term 2 x a &ee( 2. *ersonal data name, a e 0hi h ris( @ 18 . W3/ yrs old1 record to determine hi h ris( ?A3%. ?ome base moms record. Sex 0 pseudocyesis or false pre nancy on men . &omen1 5ouvade syndrome dad experiences &hat mom oes throu h lihi1 Address, civil status, reli ion, culture . beliefs &ith respect, non =ud mental -ccupation financial condition or occupational ha4ards, education bac( round level (no&led e 1. ,reRuency of Jisit7 3. Dia nosis of *re nancy 1.1 urine exam to detect ?5! at #9 199th day. ;9 C9 day pea( ?5!. ; &ee(s after >3*" best to et urine exam. 2.1 'lisa test test for pre detects beta subunit of ?5! as early as C 19days 3.1 ?ome pre (it do it yourself #. Aaseline Data7 J$S esp. A*, monitor &t. 0increase &t 1st si n preeclampsia1 =ei&%t Monito in& ,irst )rimester7 +ormal :ei ht ain 1./ 3 lbs 0./ 1lb$month1 Second trimester7 normal &ei ht ain 19 12 lbs 0# lbs$month1 01 lb$&(1 )hird trimester7 normal &ei ht ain 19 12 lbs 0# lbs$ month1 0 1lb$&(1 3inimum &t ain 29 2/ lbs -ptimal &t ain 2/ 3/ lbs /. -bstetrical Data7 nullipara no pre nancy a. 4 a(i!a" T of pre nancy b. $a a " T of viable pre nancy Jiability the ability of the fetus to live outside the uterus at the earliest possible estational a e. a e of viability " 29 2# &(s )erm 3C #2 &(s, *reterm "29 3C &ee(s abortion @29 &ee(s Sample 5ases7 1 abortion !)*A> 1 2nd mo 2 9 91 9 !2 *9 1 #9th A-! 1 3;th A-! 2 misc 1 t&ins 1 #th month !) * A > ;12 2 # 3/ A-! !; *3 !* !)*A> # 2 # 11 1 1

1 3Gth &ee( 1 miscarria e 1 stillbirth 33 A-! 0considered as para1 1 pre 3rd &( 1 33 * 1 #1st > 1 abort A 1 still 3G 1 triplet 32 1 #th mon c. 6mportant 'stimates7

!* ;#

!)*A> ; 2 2 1/

1. Na&ele>s Rule use to determine expected date of delivery !et >3* "3D C D1 Apr"Dec >3* Xan ,eb 3ar 3 D U DG DC no year >3* Xan 2/, 9# DG DC 19 $ 32 $ 9# " 1 add 1 month to month 11$31$9# 'DD 2. McDonal!>s Rule to determine a e of estation 6+ :''PS ,2+D65 ?) L C$8EA-! in :P

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,undic ?t L C E A-! in &ee(s 8 ,r sypmhisis pubis to fundus 2# L C E21 &(s 8 3. Ba t%olome3>s Rule to determine a e of estation by proper location of fundus at abdominal cavity. 3 months above sym pub / months level of umbilicus G months belo& 4yphoid 19 months level of 8 months due to li htenin #. Haases ule , to determine len th of the fetus in cm. ,ormula7 1st O of pre , sRuare Y month 2nd O of pre , x Y month by / 3mos x 3 E Gcm # mos x # E 1; cm 19 x / E /9 cm 1st O of pre / x / E 2/ cm ; x / E 39 cm C x / E 3/ cm 8 x / E #9 cm G x / E #/ cm 2nd O of pre

d. tetanus immuni4ations prevents tetanus neonatum "mom &ith complete 3 doses D*) youn a e considered as ))1 . 2. Ae in ))3 ))1 any time durin pre nancy ))2 # &(s after ))1 3 yrs protection ))3 ; months after ))2 / yrs protection ))# 1 yr after ))3 19 yrs protection ))/ yr after ))# lifetime protection /. *hysical 'xamination7 A. 'xamine teeth7 si n of infection Dan er si ns of *re nancy 5 " chills$ fever " infection 5erebral disturbances 0 headache preeclampsia1 A abdominal pain 0 epi astric pain aura of impendin convulsions A boardli(e abdomen abruption placenta 6ncrease A* ?*+ Alurred vision preeclampsia Aleedin 1st trimester, abortion, ectopic pre$2nd ? mole, incompetent cervix 3rd placental anomalies S sudden ush of fluid *%-3 0premature rupture of membrane1 prone to inf. ' edema to upper ext. 0preeclampsia1 ;. *elvic 'xamination internal exam 1. empty bladder 2. universal precaution 'L) -S of cervix site for ettin specimen Site for cervical cancer $ap Smea cervical cancer " composed of sRuamous columnar tissue %esult7 5lass 6 " normal 5lass 66A acytolo y but no evidence of mali nancy A su estive of infl. 5lass 666 cytolo y su estive of mali nancy 5lass 6J cytolo y stron ly su estive of mali nancy 5lass J cytolo y conclusive of mali nancy Sta&es of Ce (ical Cance Sta e 9 carcinoma insitu 1 cancer confined to cervix

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2 " cancer extends to va ina 3 pelvis metastasis # affection to bladder . rectum ?. Leopol!>s Maneu(e *urpose7 is done to determine the attitude, fetal presentation lie, presentin part, de ree of descent, an estimate of the si4e, and number of fetuses, position, fetal bac( . fetal heart tone " use palmS :arm palm. *rep mom7 1. 'mpty bladder 2. *osition of mom"supine &ith (nee flex 0dorsal recumbent to relax abdominal muscles1 *rocedure7 /st maneu(e 7 place patient in supine position &ith (nees sli htly flexedN put to&el under head and ri ht hipN &ith both hands palpate upper abdomen and fundus. Assess si4e, shape, movement and firmness of the part to determine presentation 1n! Maneu(e " &ith both hands movin do&n, identify the bac( of the fetus 0 to hear fetal heart sound1 &here the ball of the stethoscope is placed to determine ,?). !et J$S0before 2 nd maneuver1 *% to diff fundic soufflZ 0,?%1 . uterine soufflZ. 2terine soufflZ maternal ? rate 0 ! Maneu(e 7 usin the ri ht hand, rasp the symphis pubis part usin thumb and fin ers. )o determine de ree of en a ement. Assess &hether the presentin part is en a ed in the pelvis 1Alert 7 if the head is en a ed it &ill not be movable1. .t% Maneu(e " the 'xaminer chan es the position by facin the patients feet. :ith t&o hands, assess the descent of the presentin part by locatin the cephalic prominence or bro&. )o determine attitude relationship of fetus to 1 another. :hen the bro& is on the same side as the bac(, the head is extended. :hen the bro& is on the same side as the small parts, the head &ill be flexed and vertex presentin . Attitude relationship of fetus to a part or de ree of flexion ,ull flexion &hen the chin touches the chest @.Assessment of 'etal =ell-Bein&A. Daily 'etal Mo(ement Countin& 8D'MC9 ,be in 2C &ee(s 3om" be in after meal " brea(fast a. Ca !iff count to /6 met%o! one method currently available 011 Ae in at the same time each day 0usually in the mornin , after brea(fast1 and count each fetal movement, notin ho& lon it ta(es to count 19 fetal movements 0,3s1 021 'xpected findin s 19 movements in 1 hour or less 31 :arnin si ns a.1 more then 1 hour to reach 19 movements b.1 less then 19 movements in 12 hours0non"reactive" fetal distress1 c.1 lon er time to reach 19 ,3s than on previous days d.1 movement are becomin &ea(er, less vi orous 3ovement alarm si nals " @ 3 ,3s in 12 hours #.1 &arnin si ns should be reported to healthcare provider immediatelyN often reRuire further testin . 'xamples7 nonstress test 0+S)1, bio raphical profile 0A**1 A. Nonst ess test to determine the response of the fetal heart rate to activity 6ndication pre nancies at ris( for placental insufficiency *ostmaturity a.1 pre nancy induced hypertension 0*6?1, diabetes b.1 &arnin si ns noted durin D,35 c.1 maternal history of smo(in , inadeRuate nutrition $ oce!u e" Done &ithin 39 minutes &herein the mother is in semi"fo&lers position 0&$ fetal monitor1N external monitor is applied to document fetal activityN mother activates the Hmar( buttonI on the electronic monitor &hen she feels fetal movement. Attach external noninvasive fetal monitors 1. tocot ans!uce over fundus to detect uterine contractions and fetal movements 0,3s1 2. ult asoun! t ans!uce over abdominal site &here most distinct fetal heart sounds are detected 3. monitor until at least 2 ,3s are detected in 29 minutes

1:

1;
%esult7 +oncreative +onstress +ot !ood %eactive %esponsive is %eal !ood #nte p etation of esults i. eacti(e esult 1. Aaseline ,?% bet&een 129 and 1;9 beats per minute 2. At least t&o accelerations of the ,?% of at least 1/ beats per minute, lastin at least 1/ seconds in a 19 to 29 minute period as a result of ,3 3. !ood variability normal irre ularity of cardiac rhythm representin a balanced interaction bet&een the parasympathetic 0decreases ,?%1 and sympathetic 0increase ,?%1 nervous systemN noted as an uneven line on the rhythm strip. #. result indicates a healthy fetus &ith an intact nervous system ii. Non eacti(e esult 1. Stated criteria for a reactive result are not met 2. 5ould be indicative of a compromised fetus. %eRuires further evaluation &ith another +S), biophysical profile, 0A**1 or contraction stress test 05S)1 G. Healt% teac%in&s a. Nut ition do nutritional assessment daily food inta(e ?i h ris( moms7 1. *re nant teena ers lo& compliance to heath re imen. 2. 'xtremes in &t under&ei ht, over &t candidate for ?*+, D3 3. >o& socio economic status #. Je etarian mom decrease 5?-+ needs Jit A12 cyanocobalamin formation of folic acid needed for cell D+A . %A5 formation. 0Decrease folic acid spina bifida$open neural tube defect1 ?o& many Pcal 5?- x#,5?-+ x#, fats x G Recommen!e! Nut ient ReAui ement t%at inc eases Du in& $ e&nancy Nut ients ReAui ements 'oo! Sou ce Calo ies 399 calories$day above the 5aloric increase should reflect 'ssential to supply ener y for prepre nancy daily reRuirement - ,oods of hi h nutrient value such - increased metabolic rate to maintain ideal body &ei ht as protein, complex carbohydrates and meet ener y reRuirement to - utili4ation of nutrients 0&hole rains, ve etables, fruits1 - Jariety of foods representin foods - protein sparin so it can be used activity level - Ae in increase in second sources for the nutrients reRuirin for trimester durin pre nancy - !ro&th of fetus - 2se &ei ht ain pattern - +o more than 39Q fat - Development of structures as an indication of reRuired for pre nancy includin adeRuacy of calorie inta(e. placenta, amniotic fluid, and - ,ailure to meet caloric tissue ro&th. reRuirements can lead to (etosis as fat and protein are used for ener yN (etosis has been associated &ith fetal dama e. $ otein 'ssential for7 - ,etal tissue ro&th - 3aternal tissue ro&th includin uterus and breasts - Development of essential pre nancy structures - ,ormation of red blood cells and plasma proteins < 6nadeRuate protein inta(e has been associated &ith onset of pre nancy induces hypertension 0*6?1 ;9 m $day or an increase of 19Q above daily reRuirements for a e roup Adolescents have a hi her protein reRuirement than mature &omen since adolescents must supply protein for their o&n ro&th as &ell as protein t meet the pre nancy reRuirement *rotein increase should reflect - >ean meat, poultry, fish - ' s, cheese, mil( - Dried beans, lentils, nuts - :hole rains < ve etarians must ta(e note of the amino acid content of 5?-+ foods consumed to ensure in estion of sufficient Ruantities of all amino acids if no ,3 after #9 minutes provide &oman &ith a li ht snac( or ently stimulate fetus throu h abdomen if no ,3 after 1 hour further testin may be indicated, such as a 5S)

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Calcium-$%osp%o ous 'ssential for - !ro&th and development of fetal s(eleton and tooth buds - 3aintenance of minerali4ation of maternal bones and teeth - 5urrent research is 7 Demonstratin an association bet&een adeRuate calcium inta(e and the prevention of pre nancy induce hypertension # on 'ssential for - 'xpansion of blood volume and red blood cells formation - 'stablishment of fetal iron stores for first fe& months of life 5alcium increases of - 1299 m $day representin an increase of /9Q above prepre nancy daily reRuirement. - 1;99 m $day is recommended for the adolescent. 19 mc $day of vitamin D is reRuired since it enhances absorption of both calcium and phosphorous 5alcium increases should reflect7 - dairy products 7 mil(, yo urt, ice cream, cheese, e yol( - &hole rains, tofu - reen leafy ve etables - canned salmon . sardines &$ bones - 5a fortified foods such as oran e =uice - Jitamin D sources7 fortified mil(, mar arine, e yol(, butter, liver, seafood 6ron increases should reflect - liver, red meat, fish, poultry, e s - enriched, &hole rain cereals and breads - dar( reen leafy ve etables, le umes - nuts, dried fruits - vitamin 5 sources7 citrus fruits . =uices, stra&berries, cantaloupe, broccoli or cabba e, potatoes - iron from food sources is more readily absorbed &hen served &ith foods hi h in vit 5

Binc 'ssential for < the formation of en4ymes < maybe important in the prevention of con enital malformation of the fetus. 'olic Aci!C 'olacinC 'olate 'ssential for - formation of red blood cells and prevention of anemia - D+A synthesis and cell formationN may play a role in the prevention of neutral tube defects 0spina bifida1, abortion, abruption placenta A!!itional ReAui ements Mine als - iodine - 3a nesium - Selenium +itamins ' )hiamine %iborlavin *yridoxine 0 A;1

39 m $day representin a doublin of the pre nant daily reRuirement - Ae in supplementation at 39" m $day in second trimester, since diet alone is unable to meet pre nancy reRuirement - ;9 129 m $day alon &ith copper and 4inc supplementation for &omen &ho have lo& hemo lobin values prior to pre nancy or &ho have iron deficiency anemia. - C9 m $day of vitamin 5 &hich enhances iron absorption - inadeRuate iron inta(e results in maternal effects anemia depletion of iron stores, decreased ener y and appetite, cardiac stress especially labor and birth - fetal effects decreased availability of oxy en thereby affectin fetal ro&th < iron deficiency anemia is the most common nutritional disorder of pre nancy. 1/mc $day representin an increase of 3 m $day over prepre anant daily reRuirements. #99 mc $day representin an increase of more then 2 times the daily prepre nant reRuirement. 399mc $day supplement for &omen &ith lo& folate levels or dietary deficiency # servin s of rains$day

Minc increases should reflect - liver, meats - shell fish - e s, mil(, cheese - &hole rains, le umes, nuts 6ncreases should reflect - liver, (idney, lean beef, veal - dar( reen leafy ve etables, broccoli, le umes. - :hole rains, peanuts

1C/ mc $day 329 m $day ;/ mc $day 19 m $day 1./ m $day 1.; m $day 2.2 m $day

6ncreased reRuirements of pre nancy can easily be met &ith a balanced diet that meets the reRuirement for calories and includes food sources hi h in the other nutrients needed durin pre nancy. Jit stored in body. )a(in it not needed fat soluble vitamins. ?ard to excrete.

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A12 +iacin 2.2 m day 1C m $day

1.Sexual Acti(ity a.1 should be done in moderation b.1 should be done in private place c.1 mom placed in comfy pos, sidelyin or mom on top d.1 avoided ; &ee(s prior to 'DD e.1 avoid blo&in or air durin cunnilin us f.1 chan es in sexual desire of mom durin pre " air embolism 5han es in sexual desire7 a.1 1st tri decrease desire due to bodily chan es b.1 2nd trimester increased desire due to increase estro en that enhances lubrication c.1 3rd trimester decreased desire 5ontraindication in sex7 1. va inal spottin 1st trimester threatened abortion 2nd trimester placenta previa 2. incompetent cervix 3. preterm labor #. premature rupture of membrane 3. Exe cise , to stren then muscles used durin delivery process - principles of exercise 1.1 Done in moderation. 2.1 3ust be individuali4ed :al(in best exercise SRuattin stren then muscles of perineum. 6ncrease circulation to perineum. SRuat feet flat on floor )ailor Sittin 1 le in front of other le 0 6ndian seat1 %aise buttoc(s 1st before head to prevent postural hypotension di44iness &hen chan in position shoulder circlin exercise" stren then chest muscles pelvic roc(in $pelvic tilt" exercise relieves lo& bac( pain . maintain ood posture < arch bac( standin or (neelin . ,our extremities on floor

Pe el 'xercise stren then pulococcy eal muscles " as if hold urine, release 19x or muscle contraction Abdominal 'xercise stren thens muscles of abdominal done as if blo&in candle .. C%il!)i t% $ epa ation" -verall oal7 to prepare parents physically and psycholo ically &hile promotin &ellness behavior that can be used by parents and family thus, helpin them achieved a satisfyin and en=oyin childbirth experience. a. *sychophysical 1. B a!ley Met%o! Dr. %obert Aradley advocated active participation of husband at delivery process. Aased on imitation of nature. ,eatures7 1.1 dar(ened rm 2.1 Ruiet environment 3.1 relaxation tech #.1 closed eye . appearance of sleep 2. 4 antly Dic: Rea! Met%o! fear leads to tension &hile tension leads to pain b. *sychosexual 1. 2it7in&e met%o! pre , labor . birth . care of ne&born is an impt turnin pt in &omans life cycle " flo& &ith contraction than stru le &ith contraction c. *sychoprophylaxis prevention of pain 1. Lama7e7 Dr. ,erdinand >ama4e reR. disciple, conditionin . concentration. ?usband is coach ,eatures7 1. 5onscious relaxation 2. 5leansin breathe inhale nose, exhale mouth 3. 'ffleura e entle circular massa e over abdominal to relieve pain

1<

1=
#. ima in sensate focus <. Diffe ent Met%o!s of !eli(e y" 1.1 birthin chair bed convertible to chair semifo&lers 2.1 birthin bed dorsal recumbent pos 3.1 sRuattin relives lo& bac( pain durin labor pain #.1 leboyers &arm, Ruiet, dar(, comfy room. After delivery, baby ets &arm bath. /.1 Airth under ?29 bathtub labor . delivery &arm &ater, soft music. #D. #nt apa tal Notes inside '% A. Admittin the laborin 3other7 *ersonal Data7 name, a e, address, etc Aaseline Data7 v$s esppecially A*, &ei ht -bstetrical Data7 ravida T pre , para" viable pre , 22 2# &(s *hysical 'xams,*elvic 'xams A. Aasic (no&led e in 6ntrapartum. b. 1 T%eo ies of t%e Onset of La)o 1.1 uterine stretch theory 0 any hallo& or an stretched, &ill al&ays contract . expel its content1 contraction action 2.1 oxytocin theory post pit land releases oxytocin. ?ypothalamus produces oxytocin 3.1 prosta landin theory stimulation of arachidonic acid prosta landin" contraction #.1 pro esterone theory before labor, decrease pro esterone &ill stimulate contractions . labor /.1 theory of a in placenta life span of placenta #2 &(s. At 3; &(s de enerates 0leadin to contraction onset labor1. b.2. )he . $>s of la)o /. $assen&e a. 'etal %ea! is the lar est presentin part common presentin part F of its len th. Bones , ; bones S sphenoid , frontal " sinciput ' ethmoid - occuputal " occiput ) temporal * parietal 2 x 3easurement fetal head7 1. transverse diameter G.2/cm - biparietal lar est transverse - bitemporal 8 cm 2. bimastoid Ccm smallest transverse Sutu es , intermembranous spaces that allo& moldin . 1.1 sa ittal suture connects 2 parietal bones 0 sa itna1 2.1 coronal suture connect parietal . frontal bone 0cro&n1 3.1 lambdoidal suture connects occipital . parietal bone Mol!in&s" the overlappin of the sutures of the s(ull to permit passa e of the head to the pelvis 'ontanels" 1.1 Anterior fontanel bre ma, diamond shape, 3 x # cm,0 W / cm hydrocephalus1, 12 18 months after birth" close 2.1 *osterior fontanel or lambda trian ular shape, 1 x 1 cm. 5loses 2 3 months. #.1 Anteroposterior diameter " suboccipitobre matic G./ cm, complete flexion, smallest A* occipitofrontal 12cm partial flexion occipitomental 13./ cm hyper extension submentobra matic"face presentation 2. $assa&e3ay 3om 1.1 @ #GI tall 2.1 @ 18 years old 3.1 2nder&ent pelvic dislocation *elvis # main pelvic types 1. !ynecoid round, &ide, deeper most suitable 0normal female pelvis1 for pre nancy 2. Android heart shape Hmale pelvisI" anterior part pointed, posterior part shallo& 3. Anthropoid oval, ape li(e pelvis, oval shape, A* diameter &ider transverse narro& #. *latypelloid flat A* diameter narro&, transverse &ider ). *elvis 2 hip bones 2 innominate bones 3 *arts of 2 6nnominate Aones

1=

14
6leum lateral side of hips " iliac crest flarin superior border formin prominence of hips 6schium inferior portion " ischial tuberosity &here &e sit landmar( to et external measurement of pelvis *ubes ant portion symphisis pubis =unction bet&een 2 pubis 1 sacrum post portion sacral prominence landmar( to et internal measurement of pelvis 1 coccyx / small bones compresses durin va inal delivery #mpo tant Measu ements 1. Dia onal 5on=u ate measure bet&een sacral promontory and inferior mar in of the symphysis pubis. 3easurement7 11./ cm " 12./ cm basis in ettin true con=u ate. 0D5 11./ cmEtrue con=u ate1 2. )rue con=u ate$con=u ate vera measure bet&een the anterior surface of the sacral promontory and superior mar in of the symphysis pubis. 3easurement7 11.9 cm 3. -bstetrical con=u ate smallest A* diameter. *elvis at 19 cm or more. )uberoischi Diameter transverse diameter of the pelvic outlet. 6schial tuberosity approximated &ith use of fist 8 cm . above. 0. $o3e , the force actin to expel the fetus and placenta myometrium po&ers of labor a. 6nvoluntary 5ontractions b. Joluntary bearin do&n efforts c. 5haracteristics7 &ave li(e d. )imin 7 freRuency, duration, intensity .. $syc%e/$e son , psycholo ical stress &hen the mother is fi htin the labor experience a. 5ultural 6nterpretation b. *reparation c. *ast 'xperience d. Support System $ e-eminent Si&ns of La)o S.Sx7 " shootin pain radiatin to the le s " urinary freR. 1. >i htenin settin of presentin part into pelvic brim " 2 &ee(s prior to 'DD < 'n a ement" settin of presentin part into pelvic inlet 2. Araxton ?ic(s 5ontractions painless irre ular contractions 3. 6ncrease Activity of the 3other" nestin instinct. Save ener y, &ill be used for delivery. 6ncrease epinephrine #. %ipenin of the 5ervix butter soft /. decreased body &t 1./ 3 lbs ;. Aloody Sho& pin(ish va inal dischar e blood . leu(orrhea C. %upture of 3embranes rupture of &ater. 5hec( ,?) $ ematu e Ruptu e of Mem) ane 8 $ROM9 - do 6' to chec( for cord prolapse 5ontraction drop in intensity even thou h very painful 5ontraction drop in freRuently 2terus tense and$or contractin bet&een contractions Abdominal palpations +ursin 5areN Administer Anal esics 03orphine1 Attempt manual rotation for %-* or >-* most common malposition Aear do&n &ith contractions AdeRuate hydration prepare for 5S Sedation as ordered 5esarean delivery may be reRuired, especially if fetal distress is noted

Co ! $ olapse a complication &hen the umbilical cord falls or is &ashed throu h the cervix into the va ina. Dan er si ns7 *%-3 *resentin part has not yet en a ed ,etal distress *rotrudin cord form va ina

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+ursin care7 1" 5over cord &ith sterile au4e &ith saline to prevent dryin of cord so cord &ill remain slippery . prevent cord compression causin cerebral palsy. 2" Slip cord a&ay from presentin part 3" 5ount pulsation of cord for ,?) :" *rep mom for 5S *ositionin trendelenber or (nee chest position 'motional support *repare for 5esarean Section Diffe ence Bet3een T ue La)o an! 'alse La)o ,alse >abor )rue >abor 6rre ular contractions 5ontractions are re ular +o increase in intensity 6ncreased intensity *ain confined to abdomen *ain be ins lo&er bac( radiates to abdomen *ain relived by &al(in *ain intensified by &al(in +o cervical chan es 5ervical effacement . dilatation < ma=or sx of true labor. Du ation of La)o *rimipara 1# hrs . not more than 29 hrs 3ultipara 8 hrs . not W 1# hrs Effacement softenin . thinnin of cervix. 2se Q in unit of measurement Dilation &idenin of cervix. 2nit used is cm. Nu sin& #nte (entions in Eac% Sta&e of La)o 2 se ments of the uterus 1. upper uterine " fundus 2. lo&er uterine isthmus 1. 'i st Sta&e" onset of true contractions to full dilation and effacement of cervix. >atent *hase7 Assessment7 Dilations7 9 3 cm mom excited, apprehensive, can communicate ,reRuency7 every / 19 min 6ntensity mild +ursin 5are7 1. 'ncoura e &al(in " shorten 1st sta e of labor 2. 'ncoura e to void R 2 3 hrs full bladder inhibit contractions 3. Areathin chest breathin Active *hase7 Assessment7 Dilations # "8 cm 6ntensity7 moderate 3om" fears losin control of self ,reRuency R 3"/ min lastin for 39 ;9 seconds

+ursin 5are7 3 edications have meds ready A ssessment include7 vital si ns, cervical dilation and effacement, fetal monitor, etc. D dry lips oral care 0ointment1 dry linens A abdominal breathin )ransitional *hase7 Assessment7 Dilations 8 19 cm ,reRuency R 2"3 min contractions Durations #/ G9 seconds intensity7 stron 3om mood chan es &ith hyperesthesia

?yperesthesia increase sensitivity to touch, pain all over ?ealth )eachin 7 teach7 sacral pressure on lo&er bac( to inhibit transmission of pain (eep informed of pro ress controlled chest breathin +ursin 5are7 ) ires 6 nform of pro ress % estless support her breathin techniRue ' ncoura e and praise D iscomfort $el(ic Exams 'ffacement

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Dilation a. Station , landmar( used7 ischial spine " 1 station E presentin part 1cm above ischial spine if 0"1 floatin " 2 station E presentin part 2 cm above ischial spine if 0"1 floatin 9 station E level at ischial spine en a ement D 1 station E belo& 1 cm ischial spine D3 to D/ E cro&nin occurs at 2nd sta e of labor ). $ esentation/lie the relationship of the lon axis 0spine1 of the fetus to the lon axis of the mother "spine of mom and spine of fetus T3o types" b.1. >on itudinal >ie 0 *arallel1 cephalic " Jertex complete flexion ,ace Aro& $oo 'lexion 5hin Areech " 5omplete Areech thi h breast on abdomen, breast lie on thi h 6ncomplete Areech thi h rest on abdominal ,ran( le s extend to head ,ootlin sin le, double Pneelin b.2. )ransverse >ie 0*erpendicular1 or *erpendicular lie. Shoulder presentation. c. $osition , relationship of the fatal presentin part to specific Ruadrant of the mothers pelvis. Jariety7 -ccipito >-A left occipito ant 0most common and favorable position1 side of maternal pelvis >-* left occipito posterior >-* most common mal position, most painful %-* sRuattin pos on mom %-) %-A Areech" use sacrum " put stet above umbilicus S%oul!e /ac omnio!o so >ADA, >AD), >AD*, %ADA >SA left sacro anterior >S), >S*, %SA, %S), %S*

C%in / Mento >3A, >3), >3*, %3*, %3A, %3), %3* Monito in& t%e Cont actions an! 'etal %ea t Tone Spread fin ers li htly over fundus to monitor contractions $a ts of cont actions7 6ncrement or crescendo be innin of contractions until it increases Acme or apex hei ht of contraction Decrement or decrescendo from hei ht of contractions until it decreases Duration be innin of contractions to end of same contraction 6nterval end of 1 contraction to be innin of next contraction ,reRuency be innin of 1 contraction to be innin of next contraction 6ntensity " stren th of contraction 5ontraction vasoconstriction 6ncrease A*, decrease ,?) Aest time to et A* . ,?) =ust after a contraction or mid&ay of contractions *lacental reserve ;9 sec o2 for fetus durin contractions Duration of contractions shouldnt W;9 sec +otify 3D 3om has headache chec( A*, if same A*, let mom rest. 6f A* increase , notify 3D "preeclampsia Healt% teac%in&s 1.1 -( to sho&er 2.1+*- !6) stops function durin labor if &ith food" &ill cause aspiration 3.1'nema administer durin labor a.1)o cleanse bo&el b.1*revent infection c.1Sims position$side lyin

21

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12 18 inch ht enema tubin

5hec( ,?) after adm enema +ormal ,?)E 129"1;9 Si ns of fetal distress" 1.1 @129 . W1;9 2.1 mecomium stain amnion fluid 3.1 fetal thrushin hyperactive fetus due to lac( -2 2. Secon! Sta&e7 fetal sta e, complete dilation and effacement to birth. C 8 multi brin to delivery room 19cm primi brin to delivery room >ithotomy pos put le s same time up Aul in of perineum sure to come out Areathin pantin 0 teach mom1 Assist doc in doin episiotomy" to prevent laceration, &iden va inal canal, shorten 2nd sta e of labor. 'pisiotomy median less bleedin , less pain easy to repair, fast to heal, possible to reach rectum 0 urethroanal fistula1 3ediolateral more bleedin . pain, hard to repair, slo& to heal "use local or pudendal anesthesia. 6ronin the perineum to prevent laceration 3odified %it ens maneuver place to&el at perineum 1.1)o prevent laceration 2.1 :ill facilitate complete flexion . extension. 0Support head . remove secretion, chec( cord if coiled. *ull shoulder do&n . up. 5hec( time, identification of baby. Mec%anisms of la)o 1. 'n a ement " 2. Descent 3. ,lexion #. 6nternal %otation /. 'xtension ;. 'xternal rotation C. 'xpulsion T% ee pa ts of $el(is 1. 6nlet A* diameter narro&, transverse diameter &ider 2. 5avity T3o Ma*o Di(isions of $el(is 1. )rue pelvis belo& the pelvic inlet 2. ,alse pelvis above the pelvic inletN supports uterus durin pre nancy Linea Te minales dia onal ima inary line from the sacrum to the symphysis pubis that divides the false and true pelvis. +ursin 5are7 )o prevent puerperal sepsis " @ #8 hours only va inal pac( Aolus of *tocin can lead to hypotension. 3. T%i ! Sta&e" )i t% to expulsion of $lacenta -placental sta e *lacenta delivered from 3"19 minutes Si&ns of placental sepa ation 1. ,undus rises becomes firm . lobular H 5al(ins si nI 2. >en thenin of the cord 3. Sudden ush of blood placenta has 1/ 28 cotyledons

)ypes of placental delivery S%ult7 HshinyI be ins to separate from center to ed es presentin the fetal side shiny Dun:an HdirtyI be in to separate form ed es to center presentin natural side beefy red or dirty Slo&ly pull cord and &ind to clamp A%A+D) A+D%':S 3A+'2J'% ?urryin of placental delivery &ill lead to inversion of uterus. +s care for placenta7 #. 5hec( completeness of placenta.

22

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/. ;. C. 8. G. 19. 11. 12. #. 5hec( fundus 0if relaxed, massa e uterus1 5hec( bp Administer mether ine 63 03ethyler onovine 3aleate1 H'r otrate derivatives 3onitor hpn 0or ive oxytocin 6J1 5hec( perineum for lacerations Assist 3D for episiorapy ,lat on bed 5hills"due dehydration. Alan(et, ive clear liRuid"tea, in er ale, clear elatin. >et mom sleep to re ain ener y.

'ou t% Sta&e" t%e fi st /-1 %ou s afte !eli(e y of placenta recovery sta e. 3onitor v$s R 1/ for 1 hr. 2nd hr R 39 minutes. 5hec( placement of fundus at level of umbilicus. 6f fundus above umbilicus, deviation of fundus 1.1 'mpty bladder to prevent uterine atony 2.1 5hec( lochia a. 3aternal -bservations body system stabili4es b. *lacement of the ,undus c. >ochia d. *erineum % " edness '" dema ' " cchymosis D ischar es A approximation of blood loss. 5ount pad . saturation

,ully soa(ed pad 7 39 #9 cc &ei h pad. 1 ramE1cc e. Aondin interaction bet&een mother and ne&born roomin in types 1.1 Strai ht roomin in baby7 2#hrs &ith mom. 2.1 *artial roomin in7 baby in mornin , at ni ht nursery Complications of La)o Dystocia difficult labor related to7 3echanical factor due to uterine inertia slu ishness of contraction 1.1 hypertonic or primary uterine inertia - intense excessive contractions resultin to ineffective pushin - 3D administer sedative valium,$dia4epam muscle relaxant 2.1 hypotonic secondary uterine inertia" slo& irre ular contraction resultin to ineffective pushin . !ive oxytocin. *rolon ed labor normal len th of labor in primi 1# 29 hrs 3ulti 19 "1# hrs W 1# hrs in multi . W 29 hrs in primi - maternal effect exhaustion. ,etal effect fetal distress, caput succedaneum or cephal hematoma - ns care7 monitor contractions and ,?% $ ecipitate La)o - labor of @ 3 hrs. extensive lacerations, profuse bleedin , hypovolemic shoc( if &ith bleedin . 'arliest si n7 tachycardia . restlessness >ate si n7 hypotension -utstandin +ursin dx7 fluid volume deficit *ost of mom modified trendelenber 6J fast drip due fluid volume def Si ns of ?ypovolemic Shoc(7 ?ypotension )achycardia )achypnea 5old clammy s(in 6nversion of the uterus situation uterus is inside out. 3D &ill push uterus bac( inside or not hysterectomy. ,actors leadin to inversion of uterus 1.1 short cord 2.1 hurryin of placental delivery 3.1 ineffective fundal pressure ;te ine Ruptu e 5auses7 1.1 1.1*revious classical 5S 2.1>ar e baby

23

2:
3.1 6mproper use of oxytocin 06J drip1 Sx7 a.1 sudden pain b.1 profuse bleedin c.1 hypovolemic shoc( d.1 )A?AS*hysiolo ic retraction rin - Aoundary bet upper$lo&er uterine se ment AA+D>S patholo ic rin suprapubic depression a.1 si n of impendin uterine rupture Amniotic 'lui! Em)olism or placental embolism amniotic fluid or fra ments of placenta enters natural circulation resultin to embolism Sx7 dyspnea, chest pain . frothy sputum prepare7 suctionin end sta e7 D65 disseminated intravascular coa opathy" bleedin to all portions of the body eyes, nose, etc. T ial La)o measurement of head . pelvis falls on borderline. 3om iven ; hrs of labor 3ulti7 8 1#, primi 1# 29 $ ete m La)o , labor after 29 3C &ee(s1 0 abortion @29 &ee(s1 Sx7 1. premature contractions R 19 min 2. effacement of ;9 89Q 3. dilation 2"3 cm ?ome 3 t7 1. complete bed rest 2. avoid sex 3. empty bladder #. drin( 3 "# lasses of &ater full bladder inhibits contractions /. consult 3D if symptoms persist ?osp7 1. 6f cervix is closed 2 3 cm, dilation saved by administer )ocolytic a ents" halts preterm contractions.U2)-*A%" Uutopar ?cl1 1/9m incorporated /99cc Dextrose pi ybac(. 3onitor7 ,?) W 189 bpm 3aternal A* " @G9$;9 5rac(les notify 3D pulmo edema administer oral yutopar 39 minutes before d$c 6J )ocolytic 0*hil1 )erbuthaline 0Aricanyl or Arethine1 sustained tachycardia Antidote propranolol or inderal " beta"bloc(er 6f cervix is open 3D steroid dextameth4one 0betametha4one1 to facilitate surfactant maturation preventin %DS *reterm"cut cord ASA* to prevent =aundice or hyperbilirubenia. D. $ostpa tal $e io! /th sta e of labor after 2#hrs 7+ormal increase :A5 up to 39,999 cumm *uerperium covers 1st ; &(s post partum 6nvolution return of repro or an to its non pre nant state. ?yperfibrino enia " prone to thrombus formation " early ambulation *rinciples underlyin puerperium 1. )o return to +ormal and ,acilitate healin A. *hysiolo ic 5han es a.1. Systemic 5han es 1. 5ardiovascular System " the first fe& minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus addin to the &or(load of the heart. )his is critical especially to ravidocardiac mothers.

2:

2;
2. !enital tract a. 5ervix cervical openin b. Ja inal and *elvic ,loor c. 2terus return to normal ; 8 &(s. ,undus oes do&n 1 fin er breath$day until 19 th day no lon er palpable due behind symphisis pubis 3 days after post partum7 sub involuted uterus delayed healin uterus &ith bi clots of blood" a medium for bacterial ro&th" 0puerperal sepsis1" D.5 after, birth pain7 1. position prone 2. cold compress to prevent bleedin 3. mefenamic acid d. Loc%ia"bld, &bc, deciduas, microor anism. +sd . 5s &ith lochia. 1. %uba red 1st 3 days present, musty$mousy, moderate amt 2. Serosa pin( to bro&n # Gth day, limited amt 3. Alba crZme &hite 19 21 days very decreased amt dysuria " urine collection " alternate &arm . cold compress " stimulate bladder 3. 2rinary tract7 Aladder freR in urination after delivery" urinary retention &ith overflo& #. 5olon7 5onstipation due +*-, fear of bearin do&n /. *erineal area painful episiotomy site sims pos, cold compress for immediate pain after 2# hrs, hot sit4 bath, not compress sex" &hen perineum has healed ##. $ o(i!e Emotional Suppo t %eva %ubia *sycholo ical %esponses7 a. )a(in in phase dependent phase 01st three days1 mom passive, cant ma(e decisions, activity is to tell child birth experiences. +ursin 5are7 " proper hy iene b. )a(in hold phase dependent to independent phase 0# to C days1. 3om is active, can ma(e decisions ?)7 1.1 5are of ne&born 2.1 6nsert family plantin method common post partum blues$ baby blues present # / days /9"89Q moms over&helmin feelin of depression characteri4ed by cryin , despondence" inability to sleep . lac( of appetite. let mom cry therapeutic. c. >ettin o interdependent phase C days . above. 3om " redefines ne& roles may extend until child ro&s.

###. $ e(ent complications 1. Hemo %a&e bleedin of W /99cc 5S ;99 899 cc normal +SD /99 cc 6. 3 t7 1.1 2.1 3.1 #.1 'arly postpartum hemorrha e bleedin &ithin 1st 2# hrs. Aa uterine atony. 5omplications7 hypovolemic shoc(. massa e uterus until contracted cold compress modified trendelenber 6J fast drip$ oxytocin 6J drip ree laceration affects va inal s(in . mucus membrane. ree 1st de ree D muscles of va ina ree 2nd de ree D external sphincter of rectum ree 3rd de ree D mucus membrane of rectum y or relaxed uterus . profuse bleedin

1st de 2nd de 3rd de #th de

Areast feedin post pit land &ill release oxytocin so uterus &ill contract. :ell contracted uterus D bleedin E laceration - assess perineum for laceration - de ree of laceration - m t episiorapy D65 Disseminated 6ntravascular 5oa ulopathy. ?ypofibrino en" failure to coa ulate.

2;

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bleedin to any part of body hysterectomy if &ith abruption placenta m t7 A)" cryoprecipitate or fresh fro4en plasma 66. Late $ostpa tum %emo %a&e bleedin after 2# hrs retained placental fra ments 3 t7 D.5 or manual extraction of fra ments . massa in of uterus. D.5 except placenta increta, percreta, Acreta attached placenta to myometrium. 6ncreta deeper attachment of placenta to *ercreta invasion of placenta to perimetrium myometrium hysterectomy

?ematoma bluish or purple discoloration of SK tissue of va ina or perineum. - too much manipulation - lar e baby - pudendal anesthesia 3 t7 1.1 cold compress every 39 minutes &ith rest period of 39 minutes for 2# hrs 2.1 shave 3.1 incision on site, scrapin . suturin #nfection" sources of infection 1.1endo enous from &ithin body 2.1 exo enous from outside 1.1 anaerobic streptococci most common " from members health team 2.1 unhealthy sexual practices !eneral si ns of inflammation7 1. 6nflammation calor 0heat1, rubor 0red1, dolor 0pain1 tumor0s&ellin 1 2. purulent dischar es 3. fever !en m t7 1.1 supportive care 5A%, hydration, )SA, cold compress, paracetamol, J6)5, culture . sensitivity for antibiotic prolon ed use of antibiotic lead to fun al infection inflammation of perineum see eneral si ns of inflammation 2 to 3 stitches dislocated &ith purulent dischar e 3 t7 %emoval of sutures . draina e, saline, bet&een . resultin . 'ndometriosis inflammation of endometrial linin Sx7 Abdominal tenderness, pos. ,o&lers to facilitate draina e . locali4e infection oxytocin . antibiotic #+. Moti(ate t%e use of 'amily $lannin& 1.1 determine ones o&n beliefs 1st 2.1 never advice a permanent method of plannin 3.1 method of choice is an individuals choice. Natu al Met%o! the only method accepted by the 5atholic 5hurch Billin&s / Ce (ical mucus test spinnbar(eit . fernin 0estro en1 - clear, &atery, stretchable, elastic lon spinnbar(eit Basal Bo!y Tempe atu e 13th day temp oes do&n before ovulation no sex et before arisin in bed LAM lactation amenorrheal method hormone that inhibits ovulation is prolactin. breast feedin " menstruation &ill come out # ; months bottle fed 2 3 months disadvanta e of lam mi ht et pre nant Symptot%e mal , combination of AA) . cervical. Aest method Social 3ethod 1.1 coitus interuptus$ &ithdra&al " least effective method 2. coitus reservatus sex &ithout e=aculation 3. coitus interfemora HipitI #. calendar method -J2>A)6-+ count minus 1# days before next mens 01# days before next mens1 -ri o(nause formula - monitor cycle for 1 year - " et short test . lon est cycle from Xan Dec

26

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shortest 18 lon est 11 Dec 33 "11 22 unsafe days

Xune 2; " 18 8 "

21 day pill" start /th day of mens 28day pill" start 1st day of mens missed 1 pill ta(e 2 next day *hysiolo ic 3ethod" $ills combined oral contraceptives prevent ovulation by inhibitin the anterior pituitary land production of ,S? and >? &hich are essential for the maturation and rupture of a follicle. GG.GQ effective. :aitin time to become pre nant" 3 months. 5onsult -A";mos. Alerts on -ral 5ontraceptive7 "in case a mother &ho is ta(in an oral contraceptive for almost lon time plans to have a baby, she &ould &ait for at least 3 months before attemptin to conceive to provide time for the estro en and pro esterone levels to return to normal. " if a ne& oral contraceptive is prescribed the mother should continue ta(in the previously prescribed contraceptive and be in ta(in the ne& one on the first day of the next menses. " discontinue oral contraceptive if there is si ns of severe headache as this is an indication of hypertension associated &ith increase incidence of 5JA and subarachnoid hemorrha e. Si&ns of %ype tension 6mmediate Discontinuation A abdominal pain 5 chest pain ? " headache ' eye problems S severe le cramps 6f mom ?*+ stop pills S)A)S Adverse effect7 brea(throu h bleedin 5ontraindicated7 1.1 chain smo(er 2.1 extreme obesity 3.1 ?*+ #.1 D3 /.1 )hrombophlebitis or problems in clottin factors if for otten for one day, immediately ta(e the for otten tablet plus the tablet scheduled that day. 6f for otten for t&o consecutive days, or more days, use another method for the rest of the cycle and the start a ain.

D3*A depoproveda has pro esterone inhibits >? inhibits ovulation Depomedroxy pro esterone acetate 63 R 3 months " never massa e in=ected site, it &ill shorten duration +orplant has ; match stic(s li(e capsules implanted subdermally containin pro esterone. - / yrs disadvanta e if (eloid s(in - as soon as removed can become pre nant 3echanism and 5hemical Aarriers #nt aute ine De(ice 8#;D9 Action7 prevents implantation affects motility of sperm . ovum - ri ht time to insert is after delivery or durin menstruation primary indication for use of 62D - parity or T of children, if 1 (id only dont use 62D ?)7 1.1 5hec( for strin daily 2.1 3onthly chec(up 3.1 %e ular pap smear AlertsN - prevents implantation

2<

2=
most common complications7 excessive menstrual flo& and expulsion of the device 0common problem1 others7 $ eriod late 0pre nancy suspected1 Abnormal spottin or bleedin A bdominal pain or pain &ith intercourse # nfection 0abnormal va inal dischar e1 N ot feelin &ell, fever, chills S trin s lost, shorter or lon er 2terine inflammation, uterine perforation, ectopic pre nancy Con!om latex inserted to erected penis or lubricated va ina AdvN ives hi hest protection a ainst S)D female condom Alerts7 Disadvanta e7 - it lessen sexual satisfaction - it ives hi her protection in the prevention of S)Ds Diap% a&m rubberi4ed dome shaped material inserted to cervix preventin sperm to et to the uterus. %'J'%SAA>' ?t7 1.1 2.1 3.1 #.1 /.1 proper hy iene chec( for holes before use must stay in place ; 8 hrs after sex must be refitted especially if &ithout &t chan e 1/ lbs spermicide chem. Aarrier ex. ,oam 0most effective1, =ellies, creams S$effect7 )oxic shoc( syndrome

Alerts7 Should be (ept in place for about ; 8 hours Ce (ical Cap most durable than diaphra m no need to apply spermicide 5$67 abnormal pap smear 'oamsC EelliesC C eams Sur ical 3ethod A)> , Ailateral )ubal >i ation can be reversed 29Q chance. ?)7 avoid liftin heavy ob=ects +asectomy cut vas deferense. ?)7 W39 e=aculations before safe sex - 4ero sperm count, safe D#. Hi&% Ris: $ e&nancy /. Hemo %a&ic Diso !e s !eneral 3ana ement 1.1 5A% 2.1 Avoid sex 3.1 Assess for bleedin 0per pad 39 #9cc1 0&t 1 m E1cc1 #.1 2ltrasound to determine inte rity of sac /.1 Si ns of ?ypovolemic shoc( ;.1 Save dischar es for histopatholo y to determine if product of conception has been expelled or not 'i st T imeste Blee!in& abortion or eptopic A. Abortions termination of pre nancy before a e of viability 0before 29 &ee(s1 Spontaneous A)o tion- miscarria e 5ause7 1.1 chromosomal alterations 2.1 bli hted ovum 3.1 plasma erm defect 5lassifications7 a. )hreatened pre nancy is =eopardi4ed by bleedin and crampin but the cervix is closed b. 6nevitable moderate bleedin , crampin , tissue protrudes form the cervix 05ervical dilation1 Types" 1.1 5omplete all products of conception are expelled. +o m t =ust emotional supportS 2.1 6ncomplete *lacental and membranes retained. 3 t7 D.5 6ncompetent cervix abortion 3cDonalds procedure temporary circla e on cervix S$'N infection. Durin delivery, circla e is removed. +SD Sheridan permanent sur ery cervix. 5S

2=

24
c. ?abitual 3 or more consecutive pre nancies result in abortion usually related to incompetent cervix. *resent 2nd trimester d. 3issed fetus diesN product of conception remain in uterus # &ee(s or lon erN si ns of pre nancy cease. 0"1 pre test, scanty dar( bro&n bleedin 3 t7 induced labor &ith oxytocin or vacuum extraction /.1 6nduced Abortion therapeutic abortion to save life of mom. Double effect choose bet&een lesser evil.

5. Ectopic $ e&nancy occurs &hen estation is located outside the uterine cavity. common site7 tubal or ampular Dan erous site " interstitial 2nruptured )ubal rupture - missed period - sudden , sharp, severe pain. 2nilateral - abdominal pain &ithin 3 "/ &ee(s of missed radiatin to shoulder. shoulder pain 0indicative of intraperitoneal bleedin period 0maybe enerali4ed or one sided1 that extends to diaphra m and phrenic nerve1 - scant, dar( bro&n, va inal bleedin D 5ullens Si n bluish tin ed umbilicus si nifies intra peritoneal bleedin +ursin care7 syncope 0faintin 1 Jital si ns 3 t7 Administer 6J fluids Sur ery dependin on side 3onitor for va inal bleedin -vary7 oophrectomy 3onitor 6 . 2terus 7 hysterectomy

Secon! t imeste )lee!in& 5. Hy!ati!ifo m Mole Hbunch or rapesI or estational trophoblastic disease. &ith fertili4ation. *ro ressive de eneration of chorionic villi. %ecurs. " estational anomaly of the placenta consistin of a bunch of clear vesicles. )his neoplasm is formed form the sellin of the chronic villi and lost nucleus of the fertili4ed e . )he nucleus of the sperm duplicates, producin a diploid number #; LL, it ro&s . enlar es the uterus vary rapidly. 2se7 methotrexate to prevent choriocarcinoma Assessment7 'arly si ns " vesicles passed thru the va ina ?yperemesis ravidarium increase ?5! ,undal hei ht Ja inal bleedin 0 scant or profuse1 'arly in pre nancy ?i h levels of ?5! *reeclampsia at about 12 &ee(s >ate si ns hypertension before 29th &ee( Jesicles loo( li(e a H sno&stormI on sono ram Anemia Abdominal crampin Serious complications hyperthyroidism *ulmonary embolus +ursin care7 *repare D.5 Do not ive oxytoxic dru s )eachin s7 a. %eturn for pelvic exams as scheduled for one year to monitorin ?5! and assess for enlar ed uterus and risin titer could indicative of choriocarcinoma b. Avoid pre nancy for at least one year T%i ! T imeste Blee!in& F$lacenta AnomaliesG D. $lacenta $ e(ia it occurs &hen the placenta is improperly implanted in the lo&er uterine se ment, sometimes coverin the cervical os. Abnormal lo&er implantation of placenta. - candidate for 5S Sx7 fran( Ari ht red *ainless bleedin Dx7 2ltrasound Avoid7 sex, 6', enema may lead to sudden fetal blood loss Double set up7 delivery room may be converted to -%

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35

Assessment7 'n a ement 0usually has not occurred1 ,etal distress *resentation 0 usually abnormal1 Sur eon in char e of si n consent, %+ as &itness 3D explain to patient complication7 sudden fetal blood loss +ursin 5are +*Aed rest *repare to induce labor if cervix is ripe Administer 6J '. A) uptio $lacenta it is the premature separation of the placenta form the implantation site. 6t usually occurs after the t&entieth &ee( of pre nancy. -utstandin Sx7 dar( red, painful bleedin , board li(e or ri id uterus. Assessment7 5oncealed bleedin 0retroplacental1 5ouvelaire uterus 0caused by bleedin into the myometrium1"inability of uterus to contract due to hemorrha e. Severe abdominal pain Droppin coa ulation factor 0a potential for D651 5omplications7 Sudden fetal blood loss "placenta previa . vasa previa +ursin 5are7 6nfuse 6J, prepare to administer blood )ype and crossmatch 3onitor ,?% 6nsert ,oley 3easure blood lossN count pads %eport s$sx of D65 3onitor v$s for shoc( Strict 6.*lacenta succenturiata 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental fra ments if vessel is cut. *lacenta 5ircumvalata fetal side of placenta covered by chorion *lacenta 3ar inata fold side of chorion reaches =ust to the ed e of placenta Aattledore *lacenta cord inserted mar inally rather then centrally *lacenta Aipartita placenta divides into 2 lobes Jilamentous 6nsertion of cord" cord divides into small vessels before it enters the placenta Jasa *revia velamentous insertion of cord has implanted in cervical -S

,. !. ?. 6. X. P. >.

1. Hype tensi(e Diso !e s 6. $ e&nancy #n!uce! Hype tension 8$#H1" ?*+ after 2# &(s of pre nancy, solved ; &ee(s post partum. 1.1 !estational hypertension " ?*+ &ithout edema . protenuria ? &ithout '* 2.1 *re"eclampsia ?*+ &ith edema . protenuria or albuminuria ?' *$A 3.1 ?'>>* syndrome hemolysis &ith elevated liver en4ymes . lo& platelet count ##. T ansissional Hype tension , ?*+ bet&een 29 2# &ee(s ###. 5hronic or pre"existin ?ypertension ?*+ before 29 &ee(s not solved ; &ee(s post partum. )hree types of pre"eclampsia 1.1 Mil! p eeclampsia earliest si n of preeclampsia a.1 increase &t due to edema b.1 A* 1#9$G9 c.1 protenuria D1 " D2 2.1 Se(e e p eeclampsia Si ns present7 cerebral and visual disturbances, epi astric pain due to liver edema and oli uria usually indicates an impendin convulsion. A* 1;9$119 , protenuria D3 " D# 3.1 Eclampsia &ith sei4ureS 6ncrease A2+ lomerular dama e. *rovide safety.

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31

5ause of preeclampsia 1.1 idiopathic or un(no&n common in primi due to 1st exposure to chorionic villi 2.1 common in multiple pre 0t&ins1 increase exposure to chorionic villi 3.1 common to mom &ith lo& socioeconomic status due to decrease inta(e of 5?-+ Nu sin& ca e" * romote bed rest to decrease -2 demand, facilitate, sodium excretion, &ater immersion &ill cause to urinate. *" prevent convulsions by nursin measures or sei4ure precaution 1.1 dimly lit room . Ruiet calm environment 2.1 minimal handlin plannin procedure 3.1 avoid =arrin bed *" prepare the follo&in at bedside " ton ue depressor " turnin to side done A,)'% sei4ureS -bserve onlyS for safely. ' ensure hi h protein inta(e 0 1 $( $day1 " +a in moderation A anti"hypertensive dru ?ydrala4ine 0 Apresoline1 5 convulsion, prevent 3 So# 5+S depressant ' valuate physical parameters for 3a nesium sulfate 3a nesium S-# )oxicity7 1. A* decrease 2. 2rine output decrease 3. %esp @ 12 #. *atella reflex absent 1st si h 3 S-# toxicity. antidote 5a luconate 0.Dia)etes Mellitus - absence of insufficient insulin 06slet of >an erhans of pancreas1 ,unction7 of insulin facilitates transport of lucose to cell Dx7 1 hr /9 r lucose tolerance test !)) +ormal lucose 89 129 m $dl @ 89 hypoclycemic 0 eu lycemia1 W 129 " hyper lycemia 3 de rees !)) of W 139 m $d> maternal effect D3 1.1 ?ypo or hyper lycemia 1st trimester hypo, 2nd 3rd trim hyper lycemic 2.1 ,reRuent infection" moniliasis 3.1 *olyhydramnios #.1 Dystocia"difficult birth due to abnormalities in fetus or mom. /.1 6nsulin reRuirement, decrease in insulin by 33Q in 1st triN /9Q increase insulin at 2nd 3rd trimester. *ost partum decrease 2/Q due placenta out. ,etal effect 1.1 hyper . hypo lycemia 2.1 macrosomia lar e estational a e baby delivered W #99 or #( 3.1 preterm birth to prevent stillbirth +e&born 'ffect 7 D3 1.1 hyperinsulinism 2.1 hypo lycemia normal lucose in ne&born #/ // m $d> hypo lycemic @ #9 m $d> ?eel stic( test et blood at heel Sx7 ?ypo lycemia hi h pitch shrill cry tremors, administer dextrose 3.1 hypocalcemia " @ Cm Q Sx7 5alcemia tetany )rousseau si n !ive calcium luconate if decrease calcium %ecommendation )herapeutic abortion 6f push throu h &ith pre nancy 1.1 antibiotic therapy" to prevent sub acute bacterial endocarditis 2.1 anticoa ulant heparin doesnt cross placenta

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5lass 6 . 66" ood pro ress for va inal delivery 5lass 666 . 6J" poor pro nosis, for va inal delivery, not 5SS +-) lithotomyS ?i h semi"fo&lers durin delivery. +o valsalva maneuver %e ional anesthesiaS >o& forcep delivery due to inability to push. 6t &ill shorten 2 nd sta e of labor. Hea t !isease 3oms &ith %?D at childhood 5lass 6 no limit to physical activity 5lass 66 sli ht limitation of activity. -rdinary activity causes fati ue . discomfort. %ecommendation of class 6 . 66 1.1 sleep 19 hrs a day 2.1 rest 39 minutes . after meal 5lass 666 " moderate limitation of physical activity. -rdinary activity causes discomfort %ecommendation7 1.1 early hospitali4ation by C months 5lass 6J. mar(ed limitation of physical activity. 'ven at rest there is fati ue . discomfort. %ecommendation7 )herapeutic abortion D##. #nt apa tal complications 1. Cesa ean Deli(e y 6ndications7 a. 3ultiple estation b. Diabetes c. Active herpes 66 d. Severe toxemia e. *lacenta previa f. Abruptio placenta . *rolapse of the cord h. 5*D primary indication i. Areech presentation =. )ransverse lie *rocedure7 a. classical vertical insertion. -nce classical al&ays classical b. >o& se ment bi(ini line type aesthetic use JAA5 va inal birth after 5S #N'ERT#L#TH " inability to achieve pre nancy. :ithin a year of attemptin it - 3ana eable S)'%6>6)U " irreversible 6mpotency inability to have an erection 1 types of infe tility 1.1 primary no pre nancy at all 2.1 Secondary 1st pre nancy, no more next pre test male 1st - more practical . less complicated - need7 sperm only - sterile bottle container 0 not plastic has chem.1 - Sims ?uhner test or post coital test. *rocedure7 sex 2 hours before test mom remains supine 1/ min after e=aculation

+ormal7 cervical mucus must be stretchable 8 19 cm &ith 1/ 29 sperm. 6f W1/ lo& sperm count Aest criteria" sperm motility for impotency ,actors7 lo& sperm count 1.1 occupation" truc( driver 2.1 chain smo(er administer7 clomid 0 chomephine citrate1 to induce spermato enesis 3 t7 !6,)E !amete 6ntra ,allopian )ransfer for lo& sperm count

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6mplant sperm in ampula 1.1 3om7 ano(ulation no ovulation. Due to increase prolactin hyperprolactinemia AdministerN parlodel 0 Aromocryptice 3esylate1 ActionN antihyper prolactineuria !ive mom clomid7 action7 to induce oo enesis or ovulation S$'7 multiple pre nancy 2.1 Tu)al Occlusion tubal bloc(a e ?x of *6D that has scarred tubes - use of 62D - appendicitis 0burst1 . scarrin E dx7 hysterosalphin o raphy used to determine tubal patency &ith use of radiopaRue material 3 t7 6J, invitrofertili4ation 0test tube baby1 'n land 1st test tube baby )o shorten 2nd sta e of laborS 1.1 fundal pressure 2.1 episiotomy 3.1 forcep delivery

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