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Stages of Fetal Growth and Development

3-4 days travel of zygote mitotic cell division begins
*Pre-embryonic Stage
a. Zygote- fertilized ovum. Lifespan of zygote from fertilization to 2 months
b. Morula mulberry-like ball with 16 50 cells, 4 days free floating & multiplication
c. Blastocyst enlarging cells that forms a cavity that later becomes the embryo. Blastocyst covering of
blastocys that later becomes placenta & trophoblast
d. Implantation/ Nidation- occurs after fertilization 7 10 days.

Fetus- 2 months to birth.
placenta previa implantation at low side of uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization corpus luteum continues to function & become source of estrogen &
progesterone while placenta is not developed.
3 processes of Implantation
1. Apposition-act of bringing together
2. Adhesion-act of being adhered or united
3. Invasion-act or instance of invading or entering as enemy.
Dicidua thickened endometrium ( Latin falling off)
* Basalis (base) part of endometrium located under fetus where placenta is delivered
* Capsularies encapsulate the fetus
* Vera remaining portion of endometrium.

Chorionic Villi- 10 11
th
day, finger life projections
3 vessels=
A unoxygenated blood
V O2 blood
A unoxygenated blood
Whartons jelly protects cord
Chorionic villi sampling (CVS) removal of tissue sample from the fetal portion of the developing
placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex
missing digits/toes.

E. Cytotrophoblast inner layer or langhans layer protects fetus against syphilis 24 wks/6 months life span
of langhans layer increase. Before 24 weeks critical, might get infected syphilis

F. Synsitiotrophoblast synsitial layer responsible production of hormone

1. Amnion inner most layer
a. Umbilical Cord- FUNIS, whitish grey, 15 55cm, 20 21. Short cord: abruptio placenta or
inverted uterus.
Long cord:cord coil or cord prolapse
b. Amniotic Fluid bag of H2O, clear, odor mousy/musty, with crystallized forming pattern,
slightly alkaline.
*Function of Amniotic Fluid:
1. cushions fetus against sudden blows or trauma
2. facilitates musculo-skeletal development
3. maintains temp
4. prevent cord compression
5. help in delivery process
****normal amount of amniotic fluid 500 to 1000cc
polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid
oligohydramnios- decrease amt of fluid kidney disease

Diagnostic Tests for Amniotic Fluid

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A. Amniocentesis empty bladder before performing the procedure.
Purpose obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac;
fluid is tested for:
1. Genetic screening- maternal serum alpha feto-protein test (MSAFP) 1
st
trimester
2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity
3
rd
trimester
Testing time 36 weeks
decreased MSAFP= down syndrome
increase MSAFP = spina bifida or open neural tube defect
*Common complication of amniocenthesis infection
*Dangerous complications spontaneous abortion
3
rd
trimester- pre term labor
Important factor to consider for amniocentesis- needle insertion site
Aspiration of yellowish amniotic fluid jaundice baby
Greenish meconium

A. Amnioscopy direct visualization or exam to an intact fetal membrane.
B. Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured
amniotic fluid)
C. Nitrazine Paper Test diff amniotic fluid & urine.
Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid.

1. Chorion where placenta is developed

Lecithin Sphingomyelin L/S
Ratio- 2:1 signifies fetal lung maturity not capable for RDS

Shake test amniotic + saline & shake
Foam test
Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity


a.Placenta (Secundines) Greek pancake, combination of chorionic villi + deciduas basalis. Size: 500g or
kg
-1 inch thick & 8 diameter
Functions of Placenta:

1. Respiratory System beginning of lung function after birth of baby. Simple diffusion

2. GIT transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If
mom hypoglycemic, fetus hypoglycemic

3. Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.

4. Circulating system achieved by selective osmosis
5. Endocrine System produces hormones

Human Chorionic Gonadrophin maintains corpus luteum alive.
Human placental Lactogen or sommamommamotropin Hormone for mammary gland
development. Has a diabetogenic effect serves as insulin antagonist
Relaxin Hormone- causes softening joints & bones
estrogen
progestin

6. It serves as a protective barrier against some microorganisms HIV,HBV

Fetal Stage Fetal Growth and Development
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Entire pregnancy days 266 280 days 37 42 weeks

Differentiation of Primary Germ layers
* Endoderm
1
st
week endoderm primary germ layer
Thyroid for basal metabolism
Parathyroid - for calcium
Thymus development of immunity
Liver lining of upper RT & GIT

* Mesoderm development of heart, musculoskeletal system, kidneys and repro organ

* Ectoderm development of brain, skin and senses, hair, nails, mucus membrane or anus &
mouth
First trimester:
1
st
month - Brain & heart development
GIT& resp Tract remains as single tube
1. Fetal heart tone begins heart is the oldest part of the body
2. CNS develops dizziness of mom due to hypoglycemic effect
Food of brain glucose complex CHO pregnant womans food (potato)

Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum source of estrogen & progesterone of infant life span end of 2
nd
month
3. Sex organ formed
4. Meconium is formed

Third Month
1. Kidneys functional
2. Buds of milk teeth appear
3. Fetal heart tone heard Doppler 10 12 weeks
4. Sex is distinguishable

Second Trimester: FOCUS length of fetus

Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 20 weeks
3. buds of permanent teeth appear

Fifth Month
1. lanugo covers body
2. actively swallows amniotic fluid
3. 19 25 cm fetus,
4. Quickening- 1
st
fetal movement. 18- 20 weeks primi, 16- 18 wks multi
5. fetal heart tone heard with or without instrument

Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present

Third trimester: Period of most rapid growth. FOCUS: weight of fetus
Seventh Month development of surfactant lecithin

Eighth Month
1. lanugo begin to disappear
2. sub Q fats deposit
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3. Nails extend to fingers

Ninth Month
1. lanugo & vernix caseosa completely disappear
2. Amniotic fluid decreases

Tenth Month bone ossification of fetal skull


Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus

A. Drugs:
Streptomycin anti TB & or Quinine (anti malaria) damage to 8
th
cranial nerve poor hearing
& deafness
Tetracycline staining tooth enamel, inhibit growth of long bone
Vitamin K hemolysis (destroy of RBC), hyperbilirubenia or jaundice
Iodides enlargement of thyroid or goiter
Thalidomides Amelia or pocomelia, absence of extremities

Steroids cleft lip or palate
Lithium congenital malformation
B. Alcohol lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char
by microcephaly
C. Smoking low birth rate
D. Caffeine low birth rate
E. Cocaine low birth rate, abruption placenta

TORCH (Terratogenic) Infections viruses
CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through
birth canal and adversely affect fetal growth and development. These infections are often characterized by
vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement).
In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the
fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus.


T toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meat
O others. Hepa A or infectious heap oral/ fecal (hand washing)
Hepa B, HIV blood & body fluids
Syphilis
R rubella German measles congenital heart disease (1
st
month) normal rubella titer 1:10
<1:10 less immunity to rubella, after delivery, mom will be given rubella vaccine. Dont get pregnant
for 3 months. Vaccine is terratogenic
C cytomegalo virus
H herpes simplex virus

II. Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes
1. Cardiovascular System increase blood volume of mom (plasma blood) 30 50% = 1500 cc of blood
- easy fatigability, increase heart workload, slight hypertrophy of ventricles,
epistaxis due to hyperemia of nasal membrane palpitation,

Physiologic Anemia pseudo anemia of pregnant women


Normal Values
Hct 32 42%
Hgb 10.5 14g/dL
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Criteria
1
st
and 3
rd
trimester.- pathologic anemia if lower
HCT should not be 33%, Hgb should not be < 11g/dL

2
nd
trimester Hct should not <32%
Hgb Shdn't < 10.5% pathologic anemia if lower

Pathogenic Anemia
- iron deficiency anemiais the most common hematological disorder. It affects toughly 20% of pregnant
women.

- Assessment reveals:
Pallor, constipation
Slowed capillary refill
Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia

Nursing Care:
Nutritional instruction kangkong, liver due to ferridin content, green leafy vegetable-alugbati,saluyot,
malunggay, horseradish, ampalaya
Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if improperly administered, hematoma.
Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs
after, black stool, constipation
Monitor for hemorrhage

Alert:
Iron from red meats is better absorbed iron form other sources
Iron is better absorbed when taken with foods high in Vit C such as orange juice
Higher iron intake is recommended since circulating blood volume is increased and heme is required
from production of RBCs

Edema lower extremities due venous return is constricted due to large belly, elevate legs above hip level.

Varicosities pressure of uterus
- use support stockings, avoid wearing knee high socks
- use elastic bandage lower to upper
-
Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position side lying with pillow under hips
or modified knee chest position

Thrombophlebitis presence of thrombus at inflamed blood vessel
- pregnant mom hyperfibrinogenemia
- increase fibrinogen
- increase clotting factor
- thrombus formation candidate

outstanding sign (+) Homan's sign pain on cuff during dorsiflexion
milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens

Mgt:
1.) Bed rest
2.) Never massage
3.) Assess + Homan sign once only might dislodge thrombus
4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute)
5.) Monitor APTT antidote for Heparin toxicity, protamine sulfate
6.) Avoid aspirin! Might aggravate bleeding.

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2. Respiratory system common problem SOB due to enlarged uterus & increase O2 demand
Position- lateral expansion of lungs or side lying position.

3. Gastrointestinal 1
st
trimester change

Morning Sickness nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30
minutes before arising bed. Nausea afternoon - small freq feeding. Vomiting in preg emesisgravida.
Metabolic alkalosis, F&E imbalance primary med mgt replace fluids.
Monitor I&O


constipation progesterone resp for constipation. Increase fluid intake, increase fiber diet
- fruits papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.
Except guava has pectin thats constipating veg petchy, malungay.
- exercise
-mineral oil excretion of fat soluble vitamins
* Flatulence avoid gas forming food cabbage

* Heartburn or pyrosis reflux of stomach content to esophagus
- small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body
mechanical

increase salivation ptyalsim mgt mouthwash

*Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for comfort

4. Urinary System frequency during 1
st
& 3
rd
trimester lateral expansion of lungs or side lying pos mgt
for nocturia
Acetyace test albumin in urine
Benedicts test sugar in urine

5. Musculoskeletal

Lordosis pride of pregnancy

Waddling Gait awkward walking due to relaxation causes softening of joints & bones
Prone to accidental falls wear low heeled shoes
Leg Cramps causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause while
pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus
Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of
fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.
Vit D for increased Ca absorption
dorsiflexion

B. Local Changes
Local change: Vagina:
V Chadwicks sign blue violet discoloration of vagina
C Goodel's sign change of consistency of cervix
I Hegar's change of consistency of isthmus (lower uterine segment)

LEUKORRHEA whitish gray, mousy odor discharge
ESTROGEN hormone, resp for leucorrhea
OPERCULUM mucus plug to seal out bacteria.
PROGESTERONE hormone responsible for operculum
PREGNANT acidic to alkaline change to protect bacterial growth (vaginitis)


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Problems Related to the Change of Vaginal Environment:
a. Vaginitits trichomonas vaginalis due to alkaline environment of vagina of pregnant mom
Flagellated protozoa wants alkaline

S&Sx:
Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema
Mgt:
FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so dont give at 1
st
trimester
1. treat dad also to prevent reinfection
2. no alcohol has antibuse effect
VAGINAL DOUCHE IQ H2O : 1 tbsp white vinegar

b. Moniliasis or candidiasis due to candida albecans, fungal infection.
Color white cheese like patches adheres to walls of vagina.

Signs & Symptoms:
Management antifungal Nistatin, genshan violet, cotrimaxole, canesten
Gonorrhea -Thick purulent discharge
Vaginal warts- condifoma acuminata due to papilloma virus
Mgt: cauterization

2. Abdominal Changes striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q
tissue avoid scratching, use coconut oil, umbilicus is protruding


3. Skin Changes brown pigmentation nose chin, cheeks chloasma melasma due to increased
melanocytes.
Brown pinkish line- linea nigra- symphisis pubis to umbilicus

4. Breast Changes increase hormones, color of areola & nipple
pre colostrums present by 6 weeks, colostrums at 3
rd
trimester

Breast self exam- 7 days after mens supine with pillow at back
quadrant B upper outer common site of cancer

Test to determine breast cancer:
1. mammography 35 to 49 yrs once every 1 to 2 yrs
50 yrs and above 1 x a yr

6. Ovaries rested during pregnancy

7. Signs & symptoms of Pregnancy
A. Presumptive s/s felt and observed by the mother but does not confirm positive diagnosis of
pregnancy . Subjective
B. Probable signs observed by the members of health team. Objective
C. Positive Signs undeniable signs confirmed by the use of instrument.

Ballotment sign of myoma
* + HCG sign of H mole
- trans vaginal ultrasound. Empty bladder
- ultrasound full bladder

placental grading rating/grade
o immature
1 slightly mature
2 moderately mature
3 placental maturity
What is deposited in placenta which signify maturity - there is calcium
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Presumptive Probable Positive
Breast changes
Urinary freq
Fatigue
Amenorrhea
Morning sickness
Enlarged uterus

Cloasma
Linea negra
Increased skin
pigmentation
Striae gravidarium
Quickening
Goodel's- change of consistency of cervix
Chadwicks- blue violet discoloration of vagina
Hegar's- change of consistency of isthmus
Elevated BBT due to increased progesterone
Positive HCG or (+)preg test

Ballottement bouncing of fetus when lower uterine is
tapped sharply
Enlarged abdomen
Braxton Hicks contractions painless irregular
contractions

Ultrasound evidence
(sonogram) full
bladder

Fetal heart tone
Fetal movement
Fetal outline
Fetal parts palpable

III. Psychological Adaptation to Pregnancy (Emotional response of mom Reva Rubin theory)
First Trimester: No tanginal signs & sx, surprise, ambivalence, denial sign of maladaptation to pregnancy.
Developmental task is to accept biological facts of pregnancy
Focus: bodily changes of preg, nutrition

Second Trimester tangible S&Sx. mom identifies fetus as a separate entity due to presence of quickening,
fantasy. Developmental task accept growing fetus as baby to be nurtured.
Health teaching: growth & development of fetus.

Third Trimester: - mom has personal identification on appearance of baby
Development task: prepare of birth & parenting of child. HT: responsible parenthood babys Layette
best time to do shopping.
Most common fear let mom listen to FHT to allay fear
Lamaze classes


VII. Pre-Natal Visit:
1. Frequency of Visit: 1
st
7 months 1x a month
8 9 months 2 x a month
10 once a week
post term 2 x a week
2. Personal data name, age (high risk < 18 &>35 yrs old) record to determine high risk HBMR. Home
base moms record. Sex ( pseudocyesis or false pregnancy on men & women)
Couvade syndrome dad experiences what mom goes through lihi)
Address, civil status, religion, culture & beliefs with respect, non judgmental
Occupation financial condition or occupational hazards, education background level knowledge

3. Diagnosis of Pregnancy
1.) urine exam to detect HCG at 40 100
th
day. 60 70 day peak HCG. 6 weeks after LMP- best to
get urine exam.
2.) Elisa test test for preg detects beta subunit of HCG as early as 7 10days
3.) Home preg kit do it yourself
4. Baseline Data: V/S esp. BP, monitor wt. (increase wt 1
st
sign preeclampsia)

Weight Monitoring
First Trimester: Normal Weight gain 1.5 3 lbs (.5 1lb/month)
Second trimester: normal weight gain 10 12 lbs (4 lbs/month) (1 lb/wk)
Third trimester: normal weight gain 10 12 lbs (4 lbs/ month) ( 1lb/wk)
Minimum wt gain 20 25 lbs
Optimal wt gain 25 35 lbs

5. Obstetrical Data:
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nullipara no pregnancy
a. Gravida- # of pregnancy
b. Para - # of viable pregnancy
Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age.
age of viability - 20 24 wks
Term -37 42 wks,
Preterm -20 37 weeks
abortion <20 weeks
Sample Cases:
1 abortion GTPAL
1 2
nd
mo 2 0 01 0
G 2
P 0

1 40
th
AOG GT P A L
1 36
th
AOG 6 1 2 2 4
2 misc
1 twins 35 AOG
1 4
th
month G6 P3

1 39
th
week
1 miscarriage GP GTPAL
1 stillbirth 33 AOG (considered as para) 4 2 4 11 1 1
1 preg 3
rd
wk

1 33 P
1 41
st
L
1 abort A
1 still 39 GP GTPAL
1 triplet 32 6 4 6 2 2 15
1 4
th
mon
c. Important Estimates:

1. Nageles Rule use to determine expected date of delivery
Get LMP -3+ 7 +1 Apr-Dec LMP Jan Feb Mar
M D Y +9 +7 no year

LMP Jan 25, 04
+9 +7
10 / 32 / 04
- 1
add 1 month to month
11/31/04 EDD

2. McDonalds Rule to determine age of gestation IN WEEKS
FUNDIC HT X 7/8=AOG in WK

Fundic Ht X 7 = AOG in weeks
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Fr sypmhisis pubis to fundus 24 X 7 =21 wks
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3. Bartholomews Rule to determine age of gestation by proper location of fundus at abdominal cavity.

3 months above sym pub
5 months level of umbilicus
9 months below zyphoid
10 months level of 8 months due to lightening

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4. Haases rule to determine length of the fetus in cm.
Formula: 1
st
of preg , square @ month
2
nd
of preg, x @ month by 5
3mos x 3 = 9cm
4 mos x 4 = 16 cm 10 x 5 = 50 cm 1
st
of preg
5 x 5 = 25 cm

6 x 5 = 30 cm
7 x 5 = 35 cm 2
nd
of preg
8 x 5 = 40 cm
9 x 5 = 45 cm

d. tetanus immunizations prevents tetanus neonatum
-mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3

TT1 any time during pregnancy
TT2 4 wks after TT1 3 yrs protection
TT3 6 months after TT2 5 yrs protection
TT4 1 yr after TT3 10 yrs protection
TT5 yr after TT4 lifetime protection

5. Physical Examination:
A. Examine teeth: sign of infection
Danger signs of Pregnancy
C - chills/ fever - infection
Cerebral disturbances ( headache preeclampsia)

A abdominal pain ( epigastric pain aura of impending convulsions

B boardlike abdomen abruption placenta
Increase BP HPN
Blurred vision preeclampsia
Bleeding 1
st
trimester, abortion, ectopic pre/2
nd
H mole, incompetent cervix
3
rd
placental anomalies

S sudden gush of fluid PROM (premature rupture of membrane) prone to inf.

E edema to upper ext. (preeclampsia)

6. Pelvic Examination internal exam
1. empty bladder
2. universal precaution
EXT OS of cervix site for getting specimen
Site for cervical cancer

Pap Smear cervical cancer
- composed of squamous columnar tissue

Result:
Class I - normal
Class IIA acytology but no evidence of malignancy
B suggestive of infl.
Class III cytology suggestive of malignancy
Class IV cytology strongly suggestive of malignancy
Class V cytology conclusive of malignancy

Stages of Cervical Cancer
Stage 0 carcinoma insitu
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1 cancer confined to cervix
2 - cancer extends to vagina
3 pelvis metastasis
4 affection to bladder & rectum

7. Leopolds Maneuver
Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent,
an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone
- use palm! Warm palm.

Prep mom:
1. Empty bladder
2. Position of mom-supine with knee flex (dorsal recumbent to relax abdominal muscles)
Procedure:
1
st
maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip;
with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part
to determine presentation

2
nd
Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound) where
the bell of the stethoscope is placed to determine FHT. Get V/S(before 2
nd
maneuver) PR to diff fundic souffl
(FHR) & uterine souffl.
Uterine souffl maternal H rate

3
rd
Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers.
To determine degree of engagement.

Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will not be
movable).

4
th
Maneuver: the Examiner changes the position by facing the patients feet. With two hands, assess the
descent of the presenting part by locating the cephalic prominence or brow. To determine attitude
relationship of fetus to 1 another.

When the brow is on the same side as the back, the head is extended. When the brow is on the same side as
the small parts, the head will be flexed and vertex presenting.

Attitude relationship of fetus to a part or degree of flexion
Full flexion when the chin touches the chest
8.Assessment of Fetal Well-Being-
A. Daily Fetal Movement Counting (DFMC) begin 27 weeks
Mom- begin after meal - breakfast

a. Cardiff count to 10 method one method currently available
(1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement,
noting how long it takes to count 10 fetal movements (FMs)
(2) Expected findings 10 movements in 1 hour or less
3) Warning signs
a.) more then 1 hour to reach 10 movements
b.) less then 10 movements in 12 hours(non-reactive- fetal distress)
c.) longer time to reach 10 FMs than on previous days
d.) movement are becoming weaker, less vigorous
Movement alarm signals - < 3 FMs in 12 hours
4.) warning signs should be reported to healthcare provider immediately; often require further testing.
Examples: nonstress test (NST), biographical profile (BPP)

B. Nonstress test to determine the response of the fetal heart rate to activity
Indication pregnancies at risk for placental insufficiency
Postmaturity
12
a.) pregnancy induced hypertension (PIH), diabetes
b.) warning signs noted during DFMC
c.) maternal history of smoking, inadequate nutrition

Procedure:
Done within 30 minutes wherein the mother is in semi-fowlers position (w/ fetal monitor); external monitor is
applied to document fetal activity; mother activates the mark button on the electronic monitor when she
feels fetal movement.

Attach external noninvasive fetal monitors
1. tocotransducer over fundus to detect uterine contractions and fetal movements (FMs)
2. ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected
3. monitor until at least 2 FMs are detected in 20 minutes
if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through
abdomen
if no FM after 1 hour further testing may be indicated, such as a CST

Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good

Interpretation of results
i. reactive result
1. Baseline FHR between 120 and 160 beats per minute
2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds
in a 10 to 20 minute period as a result of FM
3. Good variability normal irregularity of cardiac rhythm representing a balanced interaction
between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system;
noted as an uneven line on the rhythm strip.
4. result indicates a healthy fetus with an intact nervous system

ii. Nonreactive result
1. Stated criteria for a reactive result are not met
2. Could be indicative of a compromised fetus.
Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST)

9. Health teachings
a. Nutrition do nutritional assessment daily food intake
High risk moms:
1. Pregnant teenagers low compliance to heath regimen.
2. Extremes in wt underweight, over wt candidate for HPN, DM
3. Low socio economic status
4. Vegetarian mom decrease CHON needs Vit B12 cyanocobalamin formation of folic acid
needed for cell DNA & RBC formation. (Decrease folic acid spina bifida/open neural tube defect)
How many Kcal CHO x4,CHON x4, fats x 9


Recommended Nutrient Requirement that increases During Pregnancy
Nutrients Requirements Food Source
Calories
Essential to supply energy for
- increased metabolic rate
- utilization of nutrients
300 calories/day above the
prepregnancy daily requirement
to maintain ideal body weight
and meet energy requirement
Caloric increase should reflect
- Foods of high nutrient value such
as protein, complex
carbohydrates (whole grains,
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- protein sparing so it can be
used for
- Growth of fetus
- Development of structures
required for pregnancy
including placenta, amniotic
fluid, and tissue growth.
to activity level
- Begin increase in second
trimester
- Use weight gain pattern as
an indication of adequacy of
calorie intake.
- Failure to meet caloric
requirements can lead to
ketosis as fat and protein
are used for energy; ketosis
has been associated with
fetal damage.


vegetables, fruits)
- Variety of foods representing
foods sources for the nutrients
requiring during pregnancy
- No more than 30% fat

Protein
Essential for:
- Fetal tissue growth
- Maternal tissue growth
including uterus and breasts
- Development of essential
pregnancy structures
- Formation of red blood cells
and plasma proteins
* Inadequate protein intake has
been associated with onset of
pregnancy induces hypertension
(PIH)
60 mg/day or an increase of 10%
above daily requirements for
age group

Adolescents have a higher
protein requirement than
mature women since
adolescents must supply protein
for their own growth as well as
protein t meet the pregnancy
requirement


Protein increase should reflect
- Lean meat, poultry, fish
- Eggs, cheese, milk
- Dried beans, lentils, nuts
- Whole grains
* vegetarians must take note of the
amino acid content of CHON foods
consumed to ensure ingestion of
sufficient quantities of all amino acids
Calcium-Phosphorous
Essential for
- Growth and development
of fetal skeleton and tooth
buds
- Maintenance of
mineralization of maternal
bones and teeth
- Current research is :
Demonstrating an association
between adequate calcium intake
and the prevention of pregnancy
induce hypertension

Calcium increases of
- 1200 mg/day representing
an increase of 50% above
prepregnancy daily
requirement.
- 1600 mg/day is
recommended for the
adolescent. 10 mcg/day of
vitamin D is required since it
enhances absorption of both
calcium and phosphorous
Calcium increases should reflect:
- dairy products : milk, yogurt, ice
cream, cheese, egg yolk
- whole grains, tofu
- green leafy vegetables
- canned salmon & sardines w/
bones
- Ca fortified foods such as orange
juice
- Vitamin D sources: fortified milk,
margarine, egg yolk, butter, liver,
seafood
Iron
Essential for
- Expansion of blood volume and
red blood cells formation
- Establishment of fetal iron
stores for first few months of
life
30 mg/day representing a
doubling of the pregnant daily
requirement
- Begin supplementation at
30- mg/day in second
trimester, since diet alone is
unable to meet pregnancy
requirement
- 60 120 mg/day along with
copper and zinc
supplementation for women
who have low hemoglobin
values prior to pregnancy or
who have iron deficiency
anemia.
- 70 mg/day of vitamin C
Iron increases should reflect
- liver, red meat, fish, poultry,
eggs
- enriched, whole grain cereals
and breads
- dark green leafy vegetables,
legumes
- nuts, dried fruits
- vitamin C sources: citrus
fruits & juices, strawberries,
cantaloupe, broccoli or
cabbage, potatoes
- iron from food sources is
more readily absorbed when
served with foods high in vit
C
14
which enhances iron
absorption
- inadequate iron intake
results in maternal effects
anemia depletion of iron
stores, decreased energy
and appetite, cardiac stress
especially labor and birth
- fetal effects decreased
availability of oxygen
thereby affecting fetal
growth
* iron deficiency anemia is the
most common nutritional
disorder of pregnancy.

Zinc
Essential for
* the formation of enzymes
* maybe important in the
prevention of congenital
malformation of the fetus.
15mcg/day representing an
increase of 3 mg/day over
prepreganant daily
requirements.
Zinc increases should reflect
- liver, meats
- shell fish
- eggs, milk, cheese
- whole grains, legumes, nuts
Folic Acid, Folacin, Folate
Essential for
- formation of red blood
cells and prevention of
anemia
- DNA synthesis and cell
formation; may play a role
in the prevention of
neutral tube defects (spina
bifida), abortion, abruption
placenta
400 mcg/day representing an
increase of more then 2 times
the daily prepregnant
requirement. 300mcg/day
supplement for women with low
folate levels or dietary
deficiency
4 servings of grains/day
Increases should reflect
- liver, kidney, lean beef, veal
- dark green leafy vegetables,
broccoli, legumes.
- Whole grains, peanuts
Additional Requirements
Minerals
- iodine
- Magnesium
- Selenium


175 mcg/day
320 mg/day
65 mcg/day
Increased requirements of pregnancy
can easily be met with a balanced
diet that meets the requirement for
calories and includes food sources
high in the other nutrients needed
during pregnancy.
Vitamins
E
Thiamine
Riborlavin
Pyridoxine ( B6)
B12
Niacin

10 mg/day
1.5 mg/day
1.6 mg/day
2.2 mg/day
2.2 mg day
17 mg/day
Vit stored in body. Taking it not
needed fat soluble vitamins. Hard
to excrete.

2.Sexual Activity
a.) should be done in moderation
b.) should be done in private place
c.) mom placed in comfy pos, sidelying or mom on top
d.) avoided 6 weeks prior to EDD
e.) avoid blowing or air during cunnilingus
f.) changes in sexual desire of mom during preg- air embolism
Changes in sexual desire:
a.) 1
st
tri decrease desire due to bodily changes
b.) 2
nd
trimester increased desire due to increase estrogen that enhances lubrication
c.) 3
rd
trimester decreased desire
15

Contraindication in sex:
1. vaginal spotting
1
st trimester
threatened abortion
2
nd
trimester placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane

3. Exercise to strengthen muscles used during delivery process
- principles of exercise
1.) Done in moderation. 2.) Must be individualized
Walking best exercise

Squatting strengthen muscles of perineum. Increase circulation to perineum. Squat feet flat on floor

Tailor Sitting 1 leg in front of other leg ( Indian seat)

Raise buttocks 1
st
before head to prevent postural hypotension dizziness when changing position


- shoulder circling exercise- strengthen chest muscles
- pelvic rocking/pelvic tilt- exercise relieves low back pain & maintain good posture
- * arch back standing or kneeling. Four extremities on floor

Kegel Exercise strengthen pulococcygeal muscles
- as if hold urine, release 10x or muscle contraction

Abdominal Exercise strengthens muscles of abdominal done as if blowing candle

4. Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be
used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience.

a. Psychophysical
1. Bradley Method Dr. Robert Bradley advocated active participation of husband at delivery process. Based
on imitation of nature.

Features:
1.) darkened rm
2.) quiet environment
3.) relaxation tech
4.) closed eye & appearance of sleep

2. Grantly Dick Read Method fear leads to tension while tension leads to pain

b. Psychosexual
1. Kitzinger method preg, labor & birth & care of newborn is an impt turning pt in womans life cycle
- flow with contraction than struggle with contraction

c. Psychoprophylaxis prevention of pain
1. Lamaze: Dr. Ferdinand Lamaze
req. disciple, conditioning & concentration. Husband is coach
Features:
1. Conscious relaxation
2. Cleansing breathe inhale nose, exhale mouth
3. Effleurage gentle circular massage over abdominal to relieve pain
4. imaging sensate focus
16


5. Different Methods of delivery:
1.) birthing chair bed convertible to chair semifowlers
2.) birthing bed dorsal recumbent pos
3.) squatting relives low back pain during labor pain
4.) leboyers warm, quiet, dark, comfy room. After delivery, baby gets warm bath.
5.) Birth under H20 bathtub labor & delivery warm water, soft music.

IX. Intrapartal Notes inside ER
A. Admitting the laboring Mother:
Personal Data: name, age, address, etc
Baseline Data: v/s esppecially BP, weight
Obstetrical Data: gravida # preg, para- viable preg, 22 24 wks
Physical Exams,Pelvic Exams

B. Basic knowledge in Intrapartum.

b. 1 Theories of the Onset of Labor
1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content)
contraction action
2.) oxytocin theory post pit gland releases oxytocin. Hypothalamus produces oxytocin
3.) prostaglandin theory stimulation of arachidonic acid prostaglandin- contraction
4.) progesterone theory before labor, decrease progesterone will stimulate contractions & labor
5.) theory of aging placenta life span of placenta 42 wks. At 36 wks degenerates (leading to
contraction onset labor).

b.2. The 4 Ps of labor

1. Passenger
a. Fetal head is the largest presenting part common presenting part of its length.
Bones 6 bones S sphenoid F frontal - sinciput
E ethmoid O occuputal - occiput
T temporal P parietal 2 x
Measurement fetal head:
1. transverse diameter 9.25cm
- biparietal largest transverse
- bitemporal 8 cm
2. bimastoid 7cm smallest transverse

Sutures intermembranous spaces that allow molding.
1.) sagittal suture connects 2 parietal bones ( sagitna)
2.) coronal suture connect parietal & frontal bone (crown)
3.) lambdoidal suture connects occipital & parietal bone

Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis

Fontanels:
1.) Anterior fontanel bregma, diamond shape, 3 x 4 cm,( > 5 cm hydrocephalus), 12 18 months after
birth- close
2.) Posterior fontanel or lambda triangular shape, 1 x 1 cm. Closes 2 3 months.
4.) Anteroposterior diameter -
suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
occipitofrontal 12cm partial flexion
occipitomental 13.5 cm hyper extension submentobragmatic-face presentation

2. Passageway
Mom 1.) < 49 tall
17
2.) < 18 years old
3.) Underwent pelvic dislocation
Pelvis
4 main pelvic types
1. Gynecoid round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android heart shape male pelvis- anterior part pointed, posterior part shallow
3. Anthropoid oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
4. Platypelloid flat AP diameter narrow, transverse wider

b. Pelvis
2 hip bones 2 innominate bones
3 Parts of 2 Innominate Bones
Ileum lateral side of hips
- iliac crest flaring superior border forming prominence of hips
Ischium inferior portion
- ischial tuberosity where we sit landmark to get external measurement of pelvis
Pubes ant portion symphisis pubis junction between 2 pubis
1 sacrum post portion sacral prominence landmark to get internal measurement of pelvis
1 coccyx 5 small bones compresses during vaginal delivery


Important Measurements

1. Diagonal Conjugate measure between sacral promontory and inferior margin of the symphysis
pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC 11.5 cm=true
conjugate)

2. True conjugate/conjugate vera measure between the anterior surface of the sacral promontory
and superior margin of the symphysis pubis. Measurement: 11.0 cm

3. Obstetrical conjugate smallest AP diameter. Pelvis at 10 cm or more.

Tuberoischi Diameter transverse diameter of the pelvic outlet. Ischial tuberosity approximated with
use of fist 8 cm & above.

3. Power supplied by the fundus of the uterus, are implemented by uterine contractions, a process that
causes cervical dilation and then expulsion of the fetus from the uterus
the force acting to expel the fetus and placenta myometrium powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person psychological stress when the mother is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System

Pre-eminent Signs of Labor
S&Sx:
- shooting pain radiating to the legs
- urinary freq.
1. Lightening setting of presenting part into pelvic brim - 2 weeks prior to EDD
* Engagement- setting of presenting part into pelvic inlet
2. Braxton Hicks Contractions painless irregular contractions
3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase
epinephrine
18
4. Ripening of the Cervix butter soft
5. decreased body wt 1.5 3 lbs
6. Bloody Show pinkish vaginal discharge blood & leukorrhea
7. Rupture of Membranes rupture of water. Check FHT

Premature Rupture of Membrane ( PROM) - do IE to check for cord prolapse
Contraction drop in intensity even though very painful
Contraction drop in frequently
Uterus tense and/or contracting between contractions
Abdominal palpations

Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP most common malposition
Bear down with contractions
Adequate hydration prepare for CS
Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is noted

Cord Prolapse a complication when the umbilical cord falls or is washed through the cervix into the vagina.

Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord form vagina



Nursing care:
1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery &
prevent cord compression causing cerebral palsy.
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS

Positioning trendelenberg or knee chest position
Emotional support
Prepare for Cesarean Section

Difference Between True Labor and False Labor
False Labor True Labor
Irregular contractions
No increase in intensity
Pain confined to abdomen
Pain relived by walking
No cervical changes
Contractions are regular
Increased intensity
Pain begins lower back radiates to abdomen
Pain intensified by walking
Cervical effacement & dilatation * major sx
of true labor.
Duration of Labor
Primipara 14 hrs & not more than 20 hrs
Multipara 8 hrs & not > 14 hrs

Effacement softening & thinning of cervix. Use % in unit of measurement
Dilation widening of cervix. Unit used is cm.

Nursing Interventions in Each Stage of Labor

19
2 segments of the uterus
1. upper uterine - fundus
2. lower uterine isthmus

1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase:
Assessment: Dilations: 0 3 cm mom excited, apprehensive, can communicate
Frequency: every 5 10 min
Intensity mild
Nursing Care:
1. Encourage walking - shorten 1
st
stage of labor
2. Encourage to void q 2 3 hrs full bladder inhibit contractions
3. Breathing chest breathing

Active Phase:
Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self
Frequency q 3-5 min lasting for 30 60 seconds

Nursing Care:
M edications have meds ready
A ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.
D dry lips oral care (ointment)
dry linens
B abdominal breathing

Transitional Phase: intensity: strong Mom mood changes with hyperesthesia
Assessment: Dilations 8 10 cm
Frequency q 2-3 min contractions
Durations 45 90 seconds

Hyperesthesia increase sensitivity to touch, pain all over
Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain
keep informed of progress
controlled chest breathing
Nursing Care:
T ires
I nform of progress
R estless support her breathing technique
E ncourage and praise
D iscomfort

Pelvic Exams
Effacement
Dilation
a. Station landmark used: ischial spine
- 1 station = presenting part 1cm above ischial spine if (-) floating
- 2 station = presenting part 2 cm above ischial spine if (-) floating
0 station = level at ischial spine engagement
+ 1 station = below 1 cm ischial spine
+3 to +5 = crowning occurs at 2
nd
stage of labor

b. Presentation/lie the relationship of the long axis (spine) of the fetus to the long axis of the mother
-spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
cephalic - Vertex complete flexion
Face
Brow Poor Flexion
20
Chin
Breech - Complete Breech thigh breast on abdomen, breast lie on thigh
Incomplete Breech thigh rest on abdominal
Frank legs extend to head
Footling single, double
Kneeling

b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation.

c. Position relationship of the fatal presenting part to specific quadrant of the mothers pelvis.

Variety:
Occipito LOA left occipito ant (most common and favorable position) side of maternal pelvis
LOP left occipito posterior
LOP most common mal position, most painful
ROP squatting pos on mom
ROT
ROA

Breech- use sacrum LSA left sacro anterior
- put stet above umbilicus LST, LSP, RSA, RST, RSP
Shoulder/acromniodorso
LADA, LADT, LADP, RADA

Chin / Mento
LMA, LMT, LMP, RMP, RMA, RMT, RMP

Monitoring the Contractions and Fetal heart Tone
Spread fingers lightly over fundus to monitor contractions

Parts of contractions:
Increment or crescendo beginning of contractions until it increases
Acme or apex height of contraction
Decrement or decrescendo from height of contractions until it decreases
Duration beginning of contractions to end of same contraction
Interval end of 1 contraction to beginning of next contraction
Frequency beginning of 1 contraction to beginning of next contraction
Intensity - strength of contraction

Contraction vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or midway of contractions

Placental reserve 60 sec o2 for fetus during contractions
Duration of contractions shouldnt >60 sec
Notify MD

Mom has headache check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia
Health teachings
1.) Ok to shower
2.)NPO GIT stops function during labor if with food- will cause aspiration
3.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.)Sims position/side lying
12 18 inch ht enema tubing

Check FHT after adm enema
21
Normal FHT= 120-160

Signs of fetal distress-
1.) <120 &>160
2.) mecomium stain amnion fluid
3.) fetal thrushing hyperactive fetus due to lack O2

2. Second Stage: fetal stage, complete dilation and effacement to birth.

7 8 multi bring to delivery room
10cm primi bring to delivery room
Lithotomy pos put legs same time up
Bulging of perineum sure to come out
Breathing panting ( teach mom)
Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2
nd
stage of labor.
Episiotomy median less bleeding, less pain easy to repair, fast to heal, possible to reach rectum (
urethroanal fistula)
Mediolateral more bleeding & pain, hard to repair, slow to heal
-use local or pudendal anesthesia.

Ironing the perineum to prevent laceration
Modified Ritgens maneuver place towel at perineum
1.)To prevent laceration
2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull
shoulder down & up. Check time, identification of baby.

Mechanisms of labor
1. Engagement -
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion

Three parts of Pelvis 1. Inlet AP diameter narrow, transverse diameter wider
2. Cavity
Two Major Divisions of Pelvis
1. True pelvis below the pelvic inlet
2. False pelvis above the pelvic inlet; supports uterus during pregnancy


Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and
true pelvis.
Nursing Care:
To prevent puerperal sepsis - < 48 hours only vaginal pack

Bolus of Ptocin can lead to hypotension.


3. Third Stage: birth to expulsion of Placenta -placental stage placenta has 15 28 cotyledons
Placenta delivered from 3-10 minutes
Signs of placental separation
1. Fundus rises becomes firm & globular Calkins sign
2. Lengthening of the cord
3. Sudden gush of blood

Types of placental delivery
22
Shultz shiny begins to separate from center to edges presenting the fetal side shiny
Dunkan dirty begin to separate form edges to center presenting natural side beefy red or dirty

Slowly pull cord and wind to clamp BRANDT ANDREWS MANEUVER
Hurrying of placental delivery will lead to inversion of uterus.

Nsg care for placenta:
4. Check completeness of placenta.
5. Check fundus (if relaxed, massage uterus)
6. Check bp
7. Administer methergine IM (Methylergonovine Maleate) Ergotrate derivatives
8. Monitor hpn (or give oxytocin IV)
9. Check perineum for lacerations
10. Assist MD for episiorapy
11. Flat on bed
12. Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to
regain energy.

4. Fourth Stage: the first 1-2 hours after delivery of placenta recovery stage. Monitor v/s q 15 for 1 hr.
2
nd
hr q 30 minutes.
Check placement of fundus at level of umbilicus.

If fundus above umbilicus, deviation of fundus
1.) Empty bladder to prevent uterine atony
2.) Check lochia
a. Maternal Observations body system stabilizes
b. Placement of the Fundus
c. Lochia

d. Perineum
R - edness
E- dema
E - cchemosis
D ischarges
A approximation of blood loss. Count pad & saturation

Fully soaked pad : 30 40 cc weigh pad. 1 gram=1cc

e. Bonding interaction between mother and newborn rooming in types
1.) Straight rooming in baby: 24hrs with mom.
2.) Partial rooming in: baby in morning , at night nursery




Complications of Labor
Dystocia difficult labor related to:
Mechanical factor due to uterine inertia sluggishness of contraction
1.) hypertonic or primary uterine inertia
- intense excessive contractions resulting to ineffective pushing
- MD administer sedative valium,/diazepam muscle relaxant
2.) hypotonic secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give
oxytocin.

Prolonged labor normal length of labor in primi 14 20 hrs
Multi 10 -14 hrs
> 14 hrs in multi &> 20 hrs in primi
- maternal effect exhaustion. Fetal effect fetal distress, caput succedaneum or cephal hematoma
23
- nsg care: monitor contractions and FHR

Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with
bleeding.
Earliest sign: tachycardia & restlessness
Late sign: hypotension
Outstanding Nursing dx: fluid volume deficit
Post of mom modified trendelenberg
IV fast drip due fluid volume def

Signs of Hypovolemic Shock:
Hypotension
Tachycardia
Tachypnea
Cold clammy skin

Inversion of the uterus situation uterus is inside out.
MD will push uterus back inside or not hysterectomy.

Factors leading to inversion of uterus
1.) short cord
2.) hurrying of placental delivery
3.) ineffective fundal pressure

Uterine Rupture
Causes: 1.)
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:
a.) sudden pain
b.) profuse bleeding
c.) hypovolemic shock
d.) TAHBSO
Physiologic retraction ring
- Boundary bet upper/lower uterine segment
BANDLS pathologic ring suprapubic depression
a.) sign of impending uterine rupture

Amniotic Fluid Embolism or placental embolism amniotic fluid or fragments of placenta enters natural
circulation resulting to embolism
Sx:
dyspnea, chest pain & frothy sputum
prepare: suctioning
end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body eyes, nose,
etc.

Trial Labor measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor
Multi: 8 14, primi 14 20

Preterm Labor labor after 20 37 weeks) ( abortion <20 weeks)
Sx:
1. premature contractions q 10 min
2. effacement of 60 80%
3. dilation 2-3 cm

Home Mgt:
1. complete bed rest
24
2. avoid sex
3. empty bladder
4. drink 3 -4 glasses of water full bladder inhibits contractions
5. consult MD if symptoms persist

Hosp:
1. If cervix is closed 2 3 cm, dilation saved by administer Tocolytic agents- halts preterm
contractions.YUTOPAR- Yutopar Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles notify MD pulmo edema administer oral yutopar 30 minutes before d/c IV
Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) sustained tachycardia
Antidote propranolol or inderal - beta-blocker

If cervix is open MD steroid dextamethzone (betamethazone) to facilitate surfactant maturation
preventing RDS

Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.


X. Postpartal Period 5
th
stage of labor
after 24hrs :Normal increase WBC up to 30,000 cumm

Puerperium covers 1
st
6 wks post partum
Involution return of repro organ to its non pregnant state.
Hyperfibrinogenia
- prone to thrombus formation
- early ambulation

Principles underlying puerperium
1. To return to Normal and Facilitate healing

A. Physiologic Changes
a.1. Systemic Changes

1. Cardiovascular System
- the first few minutes after delivery is the most critical period in mothers because the increased in plasma
volume return to its normal state and thus adding to the workload of the heart. This is critical especially to
gravidocardiac mothers.

2. Genital tract
a. Cervix cervical opening
b. Vaginal and Pelvic Floor
c. Uterus return to normal 6 8 wks. Fundus goes down 1 finger breath/day until 10
th
day no longer
palpable due behind symphisis pubis
3 days after post partum: sub involuted uterus delayed healing uterus with big clots of blood- a medium for
bacterial growth- (puerperal sepsis)- D&C
after, birth pain:
1. position prone
2. cold compress to prevent bleeding
3. mefenamic acid

d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.
1. Ruba red 1
st
3 days present, musty/mousy, moderate amt
2. Serosa pink to brown 4 9
th
day, limited amt
3. Alba crme white 10 21 days very decreased amt
25
dysuria
- urine collection
- alternate warm & cold compress
- stimulate bladder

3. Urinary tract: Bladder freq in urination after delivery- urinary retention with overflow
4. Colon: Constipation due NPO, fear of bearing down
5. Perineal area painful episiotomy site sims pos, cold compress for immediate pain after 24 hrs, hot sitz
bath, not compress
sex- when perineum has healed

II. Provide Emotional Support Reva Rubia
Psychological Responses:
a. Taking in phase dependent phase (1
st
three days) mom passive, cant make decisions, activity is to
tell child birth experiences.
Nursing Care: - proper hygiene
b. Taking hold phase dependent to independent phase (4 to 7 days). Mom is active, can make decisions
HT:
1.) Care of newborn
2.) Insert family planting method
common post partum blues/ baby blues present 4 5 days 50-80% moms overwhelming feeling of
depression characterized by crying, despondence- inability to sleep & lack of appetite. let mom cry
therapeutic.

c. Letting go interdependent phase 7 days & above. Mom - redefines new roles may extend until
child grows.

III. Prevent complications

1. Hemorrhage bleeding of > 500cc
CS 600 800 cc normal
NSD 500 cc

I. Early postpartum hemorrhage bleeding within 1
st
24 hrs. Baggy or relaxed uterus & profuse
bleeding uterine atony. Complications: hypovolemic shock.
Mgt:
1.) massage uterus until contracted
2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip

1
st
degree laceration affects vaginal skin & mucus membrane.
2
nd
degree 1
st
degree + muscles of vagina
3
rd
degree 2
nd
degree + external sphincter of rectum
4
th
degree 3
rd
degree + mucus membrane of rectum




Breast feeding post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
- assess perineum for laceration
- degree of laceration
- mgt episiorapy

DIC Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate.
- bleeding to any part of body
- hysterectomy if with abruption placenta
26
mgt: BT- cryoprecipitate or fresh frozen plasma

II. Late Postpartum hemorrhage bleeding after 24 hrs retained placental fragments
Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta,
percreta,

Acreta attached placenta to myometrium.
Increta deeper attachment of placenta to myometrium hysterectomy
Percreta invasion of placenta to perimetrium

Hematoma bluish or purple discoloration of SQ tissue of vagina or perineum.
- too much manipulation
- large baby
- pudendal anesthesia
Mgt:
1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs
2.) shave
3.) incision on site, scraping & suturing

Infection- sources of infection
1.)endogenous from within body
2.) exogenous from outside
1.) anaerobic streptococci most common - from members health team
2.) unhealthy sexual practices
General signs of inflammation:
1. Inflammation calor (heat), rubor (red), dolor (pain) tumor(swelling)
2. purulent discharges
3. fever

Gen mgt:
1.) supportive care CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity for
antibiotic

prolonged use of antibiotic lead to fungal infection
inflammation of perineum see general signs of inflammation
2 to 3 stitches dislocated with purulent discharge
Mgt:
Removal of sutures & drainage, saline, between & resulting.
Endometriosis inflammation of endometrial lining
Sx:
Abdominal tenderness, pos.
Fowlers to facilitate drainage & localize infection oxytocin & antibiotic

IV. Motivate the use of Family Planning
1.) determine ones own beliefs 1
st

2.) never advice a permanent method of planning
3.) method of choice is an individuals choice.

Natural Method the only method accepted by the Catholic Church
Billings / Cervical mucus test spinnbarkeit & ferning (estrogen)
- clear, watery, stretchable, elastic long spinnbarkeit
Basal Body Temperature 13
th
day temp goes down before ovulation no sex
- get before arising in bed

LAM lactation amenorrheal method hormone that inhibits ovulation is prolactin.
breast feeding- menstruation will come out 4 6 months
bottle fed 2 3 months
disadvantage of lam might get pregnant
27

Symptothermal combination of BBT & cervical. Best method

Social Method 1.) coitus interuptus/ withdrawal - least effective method
2. coitus reservatus sex without ejaculation
3. coitus interfemora ipit
4. calendar method

OVULATION count minus 14 days before next mens (14 days before next mens)

Origoknause formula
- monitor cycle for 1 year
- -get short test & longest cycle from Jan Dec
- shortest 18
- longest 11

June 26 Dec 33
- 18 -11
8 - 22 unsafe days

21 day pill- start 5
th
day of mens
28day pill- start 1
st
day of mens
missed 1 pill take 2 next day

Physiologic Method-

Pills combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of
FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to
become pregnant- 3 months. Consult OB-6mos.

Alerts on Oral Contraceptive:

-in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she would
wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone
levels to return to normal.
- if a new oral contraceptive is prescribed the mother should continue taking the previously prescribed
contraceptive and begin taking the new one on the first day of the next menses.
- discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension
associated with increase incidence of CVA and subarachnoid hemorrhage.

Signs of hypertension
Immediate Discontinuation
A abdominal pain
C chest pain
H - headache
E eye problems
S severe leg cramps
If mom HPN stop pills STAT!
Adverse effect: breakthrough bleeding
Contraindicated:
1.) chain smoker
2.) extreme obesity
3.) HPN
4.) DM
5.) Thrombophlebitis or problems in clotting factors

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- if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If
forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the
start again.

DMPA depoproveda has progesterone inhibits LH inhibits ovulation
Depomedroxy progesterone acetate IM q 3 months
- never massage injected site, it will shorten duration

Norplant has 6 match sticks like capsules implanted subdermally containing progesterone.
- 5 yrs disadvantage if keloid skin
- as soon as removed can become pregnant

Mechanism and Chemical Barriers


Intrauterine Device (IUD)
Action: prevents implantation affects motility of sperm & ovum
- right time to insert is after delivery or during menstruation

primary indication for use of IUD
- parity or # of children, if 1 kid only dont use IUD

HT:
1.) Check for string daily
2.) Monthly checkup
3.) Regular pap smear
Alerts;
- prevents implantation
- most common complications: excessive menstrual flow and expulsion of the device (common problem)
- others:
P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic pregnancy
Condom latex inserted to erected penis or lubricated vagina
Adv; gives highest protection against STD female condom

Alerts:
Disadvantage:
- it lessen sexual satisfaction
- it gives higher protection in the prevention of STDs

Diaphragm rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus.
REVERSABLE

Ht:
1.) proper hygiene
2.) check for holes before use
3.) must stay in place 6 8 hrs after sex
4.) must be refitted especially if without wt change 15 lbs
5.) spermicide chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome

Alerts: Should be kept in place for about 6 8 hours

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Cervical Cap most durable than diaphragm no need to apply spermicide
C/I: abnormal pap smear

Foams, Jellies, Creams

Surgical Method BTL , Bilateral Tubal Ligation can be reversed 20% chance. HT: avoid lifting heavy objects
Vasectomy cut vas deferense.
HT: >30 ejaculations before safe sex
O zero sperm count, safe

XI. High Risk Pregnancy

1. Hemorrhagic Disorders

General Management
1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 40cc) (wt 1gm =1cc)
4.) Ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Save discharges for histopathology to determine if product of conception has been expelled or not

First Trimester Bleeding abortion or eptopic
A. Abortions termination of pregnancy before age of viability (before 20 weeks)
Spontaneous Abortion- miscarriage
Cause: 1.) chromosomal alterations
2.) blighted ovum
3.) plasma germ defect

Classifications:

a. Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is closed
b. Inevitable moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
Types:
1.) Complete all products of conception are expelled. No mgt just emotional support!
2.) Incomplete Placental and membranes retained. Mgt: D&C
Incompetent cervix abortion
McDonalds procedure temporary circlage on cervix
S/E; infection. During delivery, circlage is removed. NSD
Sheridan permanent surgery cervix. CS

c. Habitual 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.
Present 2
nd
trimester
d. Missed fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy
cease. (-) preg test, scanty dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction

5.) Induced Abortion therapeutic abortion to save life of mom. Double effect choose between lesser
evil.

C. Ectopic Pregnancy occurs when gestation is located outside the uterine cavity. common site: tubal or
ampular
Dangerous site - interstitial
Unruptured Tubal rupture
- missed period
- abdominal pain within 3 -5 weeks of missed
period (maybe generalized or one sided)
- sudden , sharp, severe pain. Unilateral
radiating to shoulder.
shoulder pain (indicative of intraperitoneal bleeding
30
- scant, dark brown, vaginal bleeding

Nursing care:
Vital signs
Administer IV fluids
Monitor for vaginal bleeding
Monitor I & O
that extends to diaphragm and phrenic nerve)
+ Cullens Sign bluish tinged umbilicus signifies
intra peritoneal bleeding
syncope (fainting)
Mgt:
Surgery depending on side
Ovary: oophrectomy
Uterus : hysterectomy


Second trimester bleeding

C. Hydatidiform Mole bunch or grapes or gestational trophoblastic disease. with fertilization. Progressive
degeneration of chorionic villi. Recurs.
- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the
selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing
a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.
Use: methotrexate to prevent choriocarcinoma
Assessment:
Early signs - vesicles passed thru the vagina
Hyperemesis gravidarium increase HCG
Fundal height
Vaginal bleeding( scant or profuse)
Early in pregnancy
High levels of HCG
Preeclampsia at about 12 weeks
Late signs hypertension before 20
th
week
Vesicles look like a snowstorm on sonogram
Anemia
Abdominal cramping
Serious complications hyperthyroidism
Pulmonary embolus
Nursing care:
Prepare D&C
Do not give oxytoxic drugs
Teachings:
a. Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged
uterus and rising titer could indicative of choriocarcinoma
b. Avoid pregnancy for at least one year
Third Trimester Bleeding Placenta Anomalies

D. Placenta Previa it occurs when the placenta is improperly implanted in the lower uterine segment,
sometimes covering the cervical os. Abnormal lower implantation of placenta.
- candidate for CS
Sx: frank
Bright red
Painless bleeding
Dx:
Ultrasound
Avoid: sex, IE, enema may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR

Assessment:
Engagement (usually has not occurred)
Fetal distress
Presentation ( usually abnormal)
Surgeon in charge of sign consent, RN as witness
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- MD explain to patient
complication: sudden fetal blood loss

Nursing Care
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV

E. Abruptio Placenta it is the premature separation of the placenta form the implantation site. It usually
occurs after the twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.

Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due
to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
-placenta previa & vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
Strict I&O
F. Placenta succenturiata 1 or 2 more lobes connected to the placenta by a blood vessel may lead to
retained placental fragments if vessel is cut.
G. Placenta Circumvalata fetal side of placenta covered by chorion
H. Placenta Marginata fold side of chorion reaches just to the edge of placenta
I. Battledore Placenta cord inserted marginally rather then centrally
J. Placenta Bipartita placenta divides into 2 lobes
K. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
L. Vasa Previa velamentous insertion of cord has implanted in cervical OS


2. Hypertensive Disorders

I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.

1.) Gestational hypertension - HPN without edema & protenuria H without EP
2.) Pre-eclampsia HPN with edema & protenuria or albuminuria HE P/A
3.) HELLP syndrome hemolysis with elevated liver enzymes & low platelet count

II. Transissional Hypertension HPN between 20 24 weeks

III. Chronic or pre-existing Hypertension HPN before 20 weeks not solved 6 weeks post partum.
Three types of pre-eclampsia
1.) Mild preeclampsia earliest sign of preeclampsia
a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2

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2.) Severe preeclampsia
Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually
indicates an impending convulsion. BP 160/110 , protenuria +3 - +4

3.) Eclampsia with seizure! Increase BUN glomerular damage. Provide safety.

Cause of preeclampsia
1.) idiopathic or unknown common in primi due to 1
st
exposure to chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake of CHON

Nursing care:
P romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause
to urinate.
P- prevent convulsions by nursing measures or seizure precaution
1.) dimly lit room . quiet calm environment
2.) minimal handling planning procedure
3.) avoid jarring bed

P- prepare the following at bedside
- tongue depressor
- turning to side done AFTER seizure! Observe only! for safely.
E ensure high protein intake ( 1g/kg/day)
- Na in moderation

A anti-hypertensive drug Hydralazine ( Apresoline)
C convulsion, prevent Mg So4 CNS depressant
E valuate physical parameters for Magnesium sulfate
Magnesium SO4 Toxicity:
1. BP decrease
2. Urine output decrease
3. Resp < 12
4. Patella reflex absent 1
st
sigh Mg SO4 toxicity. antidote Ca gluconate

3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas)
Function: of insulin facilitates transport of glucose to cell
Dx: 1 hr 50gr glucose tolerance test GTT
Normal glucose 80 120 mg/dl < 80 hypoclycemic
( euglycemia) > 120 - hyperglycemia

3 degrees GTT of > 130 mg/dL
maternal effect DM
1.) Hypo or hyperglycemia 1
st
trimester hypo, 2
nd
3
rd
trim hyperglycemic
2.) Frequent infection- moniliasis
3.) Polyhydramnios
4.) Dystocia-difficult birth due to abnormalities in fetus or mom.
5.) Insulin requirement, decrease in insulin by 33% in 1
st
tri; 50% increase insulin at 2nd 3
rd

trimester.
Post partum decrease 25% due placenta out.

Fetal effect
1.) hyper & hypoglycemia
2.) macrosomia large gestational age baby delivered > 400g or 4kg
3.) preterm birth to prevent stillbirth

Newborn Effect : DM
1.) hyperinsulinism
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2.) hypoglycemia
normal glucose in newborn 45 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer dextrose
3.) hypocalcemia - < 7mg%
Sx:
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium

Recommendation
Therapeutic abortion
If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant heparin doesnt cross placenta

Class I & II- good progress for vaginal delivery
Class III & IV- poor prognosis, for vaginal delivery, not CS!
NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver
Regional anesthesia!
Low forcep delivery due to inability to push. It will shorten 2
nd
stage of labor.

Heart disease
Moms with RHD at childhood
Class I no limit to physical activity
Class II slight limitation of activity. Ordinary activity causes fatigue & discomfort.

Recommendation of class I & II
1.) sleep 10 hrs a day
2.) rest 30 minutes & after meal

Class III - moderate limitation of physical activity. Ordinary activity causes discomfort
Recommendation:
1.) early hospitalization by 7 months

Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort.
Recommendation: Therapeutic abortion

XII. Intrapartal complications
1. Cesarean Delivery Indications:
a. Multiple gestation
b. Diabetes
c. Active herpes II
d. Severe toxemia
e. Placenta previa
f. Abruptio placenta
g. Prolapse of the cord
h. CPD primary indication
i. Breech presentation
j. Transverse lie

Procedure:
a. classical vertical insertion. Once classical always classical
b. Low segment bikini line type aesthetic use

VBAC vaginal birth after CS
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INFERTILITY - inability to achieve pregnancy. Within a year of attempting it
- Manageable
STERILITY - irreversible
Impotency inability to have an erection

2 types of infertility
1.) primary no pregnancy at all
2.) Secondary 1
st
pregnancy, no more next preg
test male 1
st

- more practical & less complicated
- need: sperm only
- sterile bottle container ( not plastic has chem.)
- Sims Huhner test or post coital test. Procedure: sex 2 hours before test
mom remains supine 15 min after ejaculation
Normal: cervical mucus must be stretchable 8 10 cm with 15 20 sperm. If >15 low sperm count
Best criteria- sperm motility for impotency
Factors: low sperm count
1.) occupation- truck driver
2.) chain smoker
administer: clomid ( chomephine citrate) to induce spermatogenesis
Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm count
Implant sperm in ampula

1.) Mom: anovulation no ovulation. Due to increase prolactin hyperprolactinemia
Administer; parlodel ( Bromocryptice Mesylate)
Action; antihyper prolactineuria
Give mom clomid: action: to induce oogenesis or ovulation
S/E: multiple pregnancy

2.) Tubal Occlusion tubal blockage Hx of PID that has scarred tubes
- use of IUD
- appendicitis (burst) & scarring
= dx: hysterosalphingography used to determine tubal patency with use of radiopaque material
Mgt: IVF invitrofertilization (test tube baby)
England 1
st
test tube baby

To shorten 2
nd
stage of labor!
1.) fundal pressure
2.) episiotomy
3.) forcep delivery