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Maternity nursing
care of mother from fertilization, pregnancy, labor, impregnation, fecundation.
Fertilization = union of ovum & spermatozoa
Pregnancy = 266 days or 280 days lunar months/ full term is 40 weeks.
1st tri. = 1-3 months or stage of organogenesis
2nd tri. = 4-6 months or stage of growth
3rd tri. = 7-9 months or stage of storage

LABOR= characteristics of true & false labor

2 Types of DELIVERY
NSD = normal spontaneous delivery
CS = low cervical classical

Gynecology = study of female reproductive organs

Andrology = study of male reproductive organs

> Antepartum = from conception to the onset of labor > Pregnancy
> Intrapartum = beginning of contraction to the 1st 4 hrs. after delivery > Labor
> Post-partum = period from 6 wks. After delivery > Delivery

Cervical dilation = from 1 to 10 cm.

Reproductive System

> Composed of:

External Genitalia
1. Mons Veneris/ mons pubis > mound of fatty tissue over symphysis pubis that cushions
& protect the bone from trauma
2. Labia Majora > longitudinal folds of pigmented skin from mons pubis-perineum
> served as protection of the external genitalia, urethra, distal vagina
> scrotum = homologue for male
3. Labia Minora/ Nymphae > soft, longitudinal skin folds bet. the labia majora
4. Clitoris > center of sexual arousal & orgasm, penis for male
5. Urethral Orifice > small opening of the urethra, loc. bet. the clitoris & vagina
> for urination & catherization in female
6. Skene’s Gland/ Paraurethral Gland > loc. Lateral to the urinary meatus & one on each
> helps to lubricate the external genitalia during coitus
7. Bartholin’s Gland/Cowper’s Gland > loc. Lateral to the vaginal opening on both sides
. lubricate the external vulva during coitus
8. Hymen > membraneous tissue wringing the vaginal opening, ruptured in 1 st coitus
9. Vestibule > flattened smooth surface inside the labia
10. Perineum > area of tissue bet. the anus & vagina, site 4 episiotomy
11. Fourchette > ridge of tissue formed by the posterior joining of the 2 labia
12. Perineal Body > perineal muscle loc. At the posterior of the fourchette

Some terms to remember:

DYSPAREUNIA = painful intercourse

EPISIOTOMY = cutting of perineum to widen the vaginal opening
EPISIOGRAPHY = repair of the perineum
ESCUTCHEON= pattern of pubic hair
= male > diamond-shape
= female > triangular-shape

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Internal Genitalia

1. Vagina > muscular, tubular, musculomembranous organ that lies bet. the rectum
> depository of semen after ejaculation, part of birth canal
> conveys the sperm to the cervix so sperm can meet the ovum
2. Uterus > hollow muscular-shaped organ, located at the lower pelvis & posterior
to the bladder & anterior to the rectum
> site for reception, retention, implantation, nourishment to the ovum


1. ANTEVERSION >long axis of the uterus bent forward on the
long axis of the vagina, normal position, 90”
2. ANTEFLEXION> long axis of the uterus bent forward on the
cervix, angle of 170
3. RETROVERTED > the fundus & the uterus bent backward on
the vagina
4. RETROFLEXED > body of uterus bent backward on the cervis


1. CORPUS > uppermost portion & forms the bulk of the uterus
2. ISTHMUS > short segment bet. the body & cervix
3. CERVIX > lowest portion of the uterus, uterine outlet


1. ENDOMETRIUM > innermost portion of the uterus
2. MYOMETRIUM > middle portion
3. PERIMETRIUM > outermost portion


1. NULLIPAROUS > never given bith to a viable infant
2. MULTIPAROUS > 2 or more pregnancy
3. GRANDMULTIPARAS > more than 6 children

3. Fallopian tubes > arise from each outer cotner of the uterine body
> provides nourishment for the fertilized ovum
> serves as conduit pipes for spermatozoa to travel
> receives the ova from the ovary


1. INTERSTITIAL PORTION > part of the tube that lies w/in the uterine wall
2. ISTHMUS > next distal part of the tube, the one cut for tubal ligation
3. AMPULLA > 3rd & longest portion, fertilization of the ovum occurs here
4. INFUNDIBULAR PORTION/ INFUNDIBULUM > 4th & most distal segment
of the tube
4. Ovaries > 2 female sex glands located on each side of the uterus
> responsible for ovulation, secretes the hormones


1. CORTEX >outer layer & where the ova & grafian follicles are located
2. MEDULLA > central layer containing nerves, lymphatic tissue

5. Breast / Mammary Glands

A. External structure
1. Nipple > raised-pigmented area
2. Areola > pigmented skin around the nipple
3. Montgomery’s tubercle > sebaceous gland of the areola
B. Internal structure
1. Glandular Tissue / Parencheyna > composed of acinicells or
milk-producing cells

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2. Lactiferous ducts/ sinuses > form passageway from the lobe to

the breast
3. Fibrous tissue > cooper’s ligament, provide support to the
mammary glands
4. Adipose tissue /stroma > provide relative size & consistency of
the breast
5. Pelvis / Pelvic Ring > bony ring in the lower portion of the trunk, serves
support & protect the reproductive & pelvic organ


1. 2 innominate flaring bones

innominate bone divided into 3 parts
1. ILIUM >upper lateral portion
2. ISCHIUM > interior portion
3. PUBIS > anterior portion
2. COCYX > below the sacrum, composed of fine small bones
3. SACRUM > upper posterior portion of the pelvic ring

1. GYNECOID > typical female pelvis w/ rounded outlet
2. ANDROID > typical male pelvis w/ heart-shaped inlet
3. ANTHROPOID > apelike pelvic w/ oval inlet
4. PLATYPELLOID > flat-female type pf pelvis w/ transverse oval

Terms to remember:
LIBIDO = sexual drive
ORGASM = highest peak/point of sexual excitement
HYSTERECTOMY = surgical removal of the uterus
OXYTOCIN = aids to constrict milk gland cells
GYNECOMASTIA = increase in male breast
MASTITIS = inflammation of the breast
MAMMOGRAPHY = genography of the mammary gland/breast examination
MASTECTOMY = surgical removal /excision of the breast
BREAST ENGORGEMENT = usually occurs 2-5 days after
PELVIMETRY = measuring of the internal & external pelvis
PERINEOGRAPHY = repair of the vagina
2 ISCHIAL TUBEROSITY = portion of the bones on w/c the person eats
ISCHIAL SPINE = small projection that extends from the lateral aspect to the pelvic cavity
SYMPHYSIS PUBIS = junction of the innominate bones at the front of the pelvis

MESTRUATION >complex cycle of events that occur in the hypothalamus, pituitary gland,
uterine endometrium, cervix & ovaries
MENARCHE > menstruation of a woman, 9-17 yrs old
MENOPAUSE >essation of menstrual flow cycles, 40-55 yrs. Old
MENSTRUAL CYCLE >eproductive cycle, periodic uterine bleeding in response to cyclic
hormonal changes (estrogern, progesterone (FSH, LH)
28 DAYS >average lenth of menstrual cycle
2-7 DAYS/3-5 > average flow of menstrual cycle
30-80 ml. Of blood > average amount of menstruation
11 mg. > iron loss during menstruation


1. ANTERIOR PITUITARY GLAND = secretes the FSH & LH hormones

FSH = for maturation of the ovum & follicle stimulating hormones
LH = for release of mature eggs & responsible for ovulation

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2. HYPOTHALAMUS = stimulates the m. cycle, gives signals


FERTILITY PERIOD > last for about 9 days

> 7 days = before ovulation period
> 1 day = during ovulation period
> 1 day = day after ovulation period

OVULATION > maturation & release of the egg from the ovary, occurs on the day 14
LMP > 1st day of the last normal menstrual cycle

COMPUTE FOR OVULATION DATE > get LMP & lenth of cycle then less 14 days

PHASES OF MENSTRUAL CYCLE > 1ST Phase: Proliferative CNS response: 5th-14th day
> 2nd Phase: Secretory/ Ovarian response: 14th-16th day
> 3rd Phase: Ischemic/ Endometrial response:
> 4th Phase: Menses/ Cervix & Cervical mucuos








External structure

1. PENIS > male organ of copulation, 4-7 inches

2. GLANS > bulging sensitive ridge tissue of the penis, most sensitive
3. PREPUCE > retractable casing of the skin, removed in circumcision
4. SCROTUM > rugated skin covered muscular pouch suspended in the perineum
Internal Organ

1. TESTES > 2 ovoid glands that lies in the perineum, diff. In size
2. EPIDIDYMIS > seminifirous tubule of each testes, 2 feet long
> reservoir for sperm storage & maturation
> responsible for absorption of seminal fluid
> responsible for the addition of substances to the s. fluid
3. VAS DEFERENS > carries sperm from the epididymis thru the inguinal canal
4. SEMINAL VESICLE> secretes a viscos portion of semen w/c has a high content
of basic sugar, protein & alkaline in ph
5. EJACULATORY DUCT > 2 ducts passed to the prostate gland, joined the

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seminal vesicle w/ the urethra

> drain seminal fluid into the prostatic urethra
6. PROSTATE GLAND > base of the urethra & ejaculatory duct
> secretes clear fluid w/ a slightly ph
FX>production of the thin, milky fluid containing citric
acid & acid phosphate
7. URETHRA > passageway of the urine & semen, 8 cm. Long
8. COWPER’S GLAND/B.G. > helps to lubricate the urethra & ensures safe passage of
the spermatozoa, homologue “ skene’s gland”
9. URETHRAL MEATUS > the urine & semen passed out
> used for catherization purposes

Terms to remember:

SEMEN > thick, whitish fluid ejaculated by man during orgasm

> composed of spermatozoa, fructose, protein
> 2.5-3.5 ml.
ASPERMIA > absence of sperm
OLIGOSPERMIA >fewer than 20 million of sperm/ml
12-20 days > for spermatozoa to travel
64-75 days > to reach maturity
VASECTOMY > surgical removal of the vas deferens
HCG > human chorionic gonadotrophin
PROSTATECTOMY > surgical removal of the prostate gland


AOG > period bet. conception & birth of a baby

> time measured from conception to the current date & measured in weeks.

> get LMP & date of prenatal visit, divided by 7


NAGELE’S RULE > subtract 3 months & add 7 days, get only the LMP


GRAVIDA >the # of pregnancies including the present & abortion
NULLIGRAVIDA =woman who has never been pregnant
PRIMIGRAVIDA =woman w/ first pregnancy
MULTIGRAVIDA = woman w/ 2nd pregnancy or more
PARITY > refers to past pregnancies (not the # of babies) that reached viability
whether or not born alive (abortion & miscarriages not included)
NULLIPARA = woman who has not carried a pregnancy to viability
PRIMIPARA = woman who carried one pregnancy to viability
MULTIPARA = woman who had 2 or more pregnancy that reached viability
GRANDMULTIPARA= woman who has had 6 or more viable pregnancies


G > the # of pregnancies including the present

TERM > the # of full term birth born @ 38-40 wks. Gestation
PRETERM > the # of preterm birth born @ 20-37 wks. Gestation
ABORTION > the 3 of abortion
LIVING > the # of living children

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MULTIPLE > the # of multiple pregnancy

20 wks. Below > considered abortion

20-37 wks. > preterm
38-40 wks. > term
42 wks. Up > post-term

SEXUALITY > multidimensional phenomenom that includes feelings, attitudes & actions.
Both biologic & cultural components, gives direction to a person’s
physical,emotional,social & intellectual responses throughout life.


1. BIOLOGIC GENDER >term used to denote chromosomal sexual dev’t.

2. GENDER/ SEXUAL IDENTITY > inner sense a person has of being male or
female, or sense of masculinity & femininity
3. GENDER ROLE > is the behaviour a person coveys about being
male or female


1. HETEROSEXUALITY >a person who finds sexual fulfillment with a

member of the opposite sex. ( male-female)
2. HOMOSEXUALITY > one who finds sexual fulfillment w/ the same sex
> male-male, female-female
3. BISEXUAL > the one who achieve sexual satisfaction from both
homosexual & heterosexual relationship
4. TRANSSEXUAL > an individual who although of one biologic
gender, feels as if he or she should be of the
opposite gender. Goes for sex change

1. CELIBACY > abstinence from sexual activity

2. MASTURBATION > self-stimulation for erotic pleasure, offers sexual release
3. EROTIC STIMULATION > the use of visual materials (magazines) for arousal
4. FETISHISM > the sexual arousal by the use of certain objects/situations

5. TRANSVESTISM > an individual who dresses to take the role of the opposite sex
6. VOYEURISM >sexual arousal by looking at another’s body
7. SADOMASOCHISM > involves inflicting pain (sadism), or receiving pain
(masochism) to achieve sexual satisfaction.
8. EXHIBITIONISM >revealing genitalia in public
9. PEDOPHILES > individuals interested in sexual encounters w/ children
10. BESTIALITY > brutal & inhuman sexual activity, ex. To animals



1. ERECTILE DYSFUNCTION> the inability to produce or maintain an erection

long enough for vaginal penetration or partner
2. PREMATURE EJACULATION> ejaculation before penile-vaginal contact
3. FAILURE TO ACHIEVE ORGASM> can be due to poor sexual technique,
concentrating too hard on achievement or possible
(-) attitudes towards sexual relationships

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4. VAGINISMUS > involuntary contraction of the muscles at the outlet of the vagina
when coitus is attempted.
5. DYSPAREUNIA > pain during coitus ( those w/ cervicitis)
6. INHIBITED SEXUAL PLEASURE >lack of desire for sexual relations, maybe a
concern of young or middle age adults

1. Chronic diseases such as peptic ulcers or CPD that cause frequent pain may
interfere w/ the overall being & interest in sexual activity

1.CHROMOSOMES > elements w/in the cell nucleus carrying genes & composed of
DNA & protein
DNA > nucleic acid that carries genetic information into the cells
DIPLOID > 46 chromosomes (23 pairs =22 somatic cells, 1 sex cell)
HAPLOID > 23 chromosomes
2. GENES >factors on a chromosome responsible for hereditary
characteristics of offspring.
> small segments of DNA contained in the chromosomes, some
recessive, some dominant, some sex-linked

Dominant > dwarfism

Recessive > sickle-cell anemia, deafness recessive
Sex-linked > hemophilia A & B, color blindness

3. ALLELES > pair of genes, 2 genes for every human trait

(1 from ovum, 1from sperm)
4. PHENOTYPE> an individuals physical appearance, determined by the alleles
5. GENOTYPE > refer’s to individuals actual gene composition

XX >female
XY > male

SEX DETERMINATION > established at the time of fertilization by the male sex

MATURE OVUM > contains haploid # of 23 chromosomes, one is always an X

MATURE SPERMATOZOAN> contains haploid # of 23 chromosomes, either an X or Y

> union of the ovum & spermatozoan

OVUM >life span of 24 hours after ovulation or 1 day

SPERMATOZOAN > life span of 48-72 hours or 2-3 days after ejaculation
into the vagina
ZONA PELLUCIDA & CORONA RADIATA> serves as protection of the ovum
from injuries

1. ACROSOME FERTILIZATION >release of proteolytic enzymes that

enable the sperm to digest the cumulus
cells & penetrate the zona pellucida.
2. CAPACITATION > process that enables the sperm to
bind to the ovum.

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> the final process that sperm must

undergo to be ready for fertilization

* After one sperm has entered, changes occur w/in the zona pellucida that
prevent other sperm from entering.

CONCEPTION (FERTILIZATION) > usually occurs w/in 12-24 hrs. after

ovulation, in the outer third (ampullar region) of the
fallopian tube.
IMPLANTATION (NIDATION) >usually occurs 8-10 days after fertilization
> about day 20 of a 28-day menstrual cycle


1. OVUM >from ovulation to fertilization = 12-24 hrs.

2. ZYGOTE > fertilization to implantation
3. BLASTOMERES > mitotic division of the zygote
4. MORULA > when there is a solid ball of cells formed by 16-50
5. BLASTOCYCST > when the morula reaches the lining of the uterus or
endometrium on the 4th-5th day
6. EMBRYO > from implantation to 5-8 wks.
7. FETUS > from 8 wks. Until term
8. CONCEPTUS > when there is developing embryo & fetus & placental
structures thru pregnancy, from all the products of


PRE-EMBRYONIC STAGE > period until primary villi appeared, usually 12-
14 days after conception


1. ECTODERM > outermost portion/layer of the embryo

Body portions formed:

2. MESODERM > middle portion/ layer of the embryo

Body portions formed:

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3. ENDODERM/ENTODERM > innermost portion of the embryo

Body portions formed:

EMBRYONIC STAGE > period from end of ovum stage until measurement reaches
3 cm or 54-56 days
FETAL STAGE > from week 9 to birth


1. 1ST TRIMESTER >rapid growth, susceptible to teratogens

2. 2nd TRIMESTER > less danger from teratogens, FHB heard thru stethoscope
3. 3rd TRIMESTER > iron stored

Terms to remember:
QUICKENING > first fetal movement felt by the mother
> 18 wks. For multipara
> 20 wks. For nullipara
VERNIX CASEOSA > a cream-cheese like structure covering the fetal skin
> for lubrication & prevent the skin from macerating
LANUGO > translucent, soft downy hair charaterstics of a new born


1. CORPUS LUTEUM > supplies most of the estrogen & progesterone in

the 1st 2 months before placenta is fully developed
> the one that functions prior to the placenta

2. DECIDUA > optimal site for blastocyst implantation

> specialized, highly magnified endometrium of pregnancy


1. DECIDUA BASALIS > portion lying directly under the blastocyst
& establishes comm.w/ the maternal blood vessels
2. DECIDUA CAPSULARIS> portion covering the blastocyst
3. DECIDUA VERA > remaining portion of the uterine lining

3. CHORIONIC VILLI >becomes the placenta, the throphoblastic layer of cells of

the blastocyst



> outer layer of the chorionic villi, is instrumental
in the production of various placental hormones
> inner layer of the chrionic villi & protects the
growing embryo & fetus from certain infectious
organisms, appear at day 12 of pregnancy
4. PLACENTA > soul of pregnancy, transmits nutrients & oxygen to the fetus &
removes waste & CO2 by diffusion

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> begins to function by the 4th week of gestation, by 14th week, it

is complete & independently functioning organ

1. ESTROGEN (PRIMARILY ESTRIOL) > stimulates the growth of muscle &
induces the synthesis of receptors of progesterone
> stimulates uterine growth, breast dev’t,
> enhances growth of all organs
> indicates placental function, fetal maturity
2. PROGESTERONE > helps for development of deciduas
> stimulates growth of acinicells for lactation
> promotes thickening & increased viscosity of cervical
mucous, relaxes uterine smooth muscle
>1st indicator of + pregnancy test & detected in the urine
(14 days) & plasma by day 8
> stimulates the male testes, responsible for maintaining
the corpus luteum
> facilitates glucose transport across the placenta
> stimulates breast dev’t. to prepare for lactogen
> antagonizes insulin
5. PROLACTIN (milk production) > increased concentration at 8 months
> suppressed by estrogen & progesterone
> increased level after placenta is delivered
> ensures lactation
6. OXYTOCIN (milk ejection) > causes uterus to contract when oxytocin levels exceed
those of estrogen & progesterone
7. MELANOTROPIN > responsible for chloasama ( mask of pregnancy), linea
nigra, deeper color of the areola & genitalia
> no ovulation during pregnancy

Terms to remember:
DECIDUALIZATION > process of deciduas, pregnancy outside the uterine cavity
DIFUSION > oxygen diffuses from maternal blood across the placental membrane into
the fetal Blood


> those that are least indicative of pregnancy
> experienced by the mother but cannot be documented by the
> experienced by the mother that can be documented by the
examiner, more reliable than presumptive signs
> are positive or true diagnostics findings of pregnancy


2 WKS. >BREAST CHANGES >feelings of tenderness, fullness, tingling,

enlargement & darkening if the areola
2 WKS. >AMENORRHEA >absence of menstruation
2 WKS. > NAUSEA, VOMITING >nausea, vomiting on arising
3 WKS > FREQUENT URINATION > sense of having to void frequently
12 WKS > FATIGUE > general feeling of tiredness
12 WKS. > UTERINE ENLARGEMENT> uterus can be palpated over the symphysis pubis
18 WKS. > QUICKENING > fetal movement felt by the mother

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22 WKS. > LINEA NIGRA > line of dark pigment on the abdomen
24 WKS. > MELASMA > dark pigment on the face
24 WKS. > STRIAE GRAVIDARUM > red streaks on the abdomen


1 WK. > SERUM LABORATORY TESTS > test of blood serum reveal the
presence of HCG

6 WKS. > CHADWICK’S SIGN > color change of the vagina from pink to
6 WKS. > GOODELL’S SIGN > softening of the cervix
6 WKS. > HEGAR’S SIGN > softening of the lower uterine segment
6 WKS. > SONOGRAPHIC EVIDENCE > characteristic ring is evident
6 WKS. > PISKACEK SIGN > enlargement & softening of the uterus
16 WKS. > BALLOTEMENT > when lower uterine segment is tapped on a
bimanual examination, the fetus can be felt to
rise against abdominal wall
20 WKS. > BRAXTON HICKS SIGN > periodic uterine tightening occurs
20 WKS. > FETAL OUTLINE FELT > fetal outline can be palpated thru the abdomen


8 WKS. > SONOGRAPHIC EVIDENCE > fetal outline can be seen & measured by
8-12 WKS. > FETAL HEART AUDIBLE > Doppler ultrasound revelals heart
20 WKS. > FETAL MOVEMENT FELT > fetal movement can be palpated thru the




> outermost fetal membrane of the bag of water
> develops from the trophoblast & contains the c.v. on its
> innermost fetal membrane of the bag of water
> develop from interior cells of the blastocyst
> covers the u. cord & covers the chorionon fetal surface of
the placenta

AMNIOTIC FLUID >cushions the fetus, allows freedom of movement & permits
skeletal development
> helps maintain body temp., acts as a source of oral fluid as
well as waste repository, serves as lubrication bet. fetus &
800-1,200 ml. = average amount

HYDRAMNIOS/ POLYHYDRAMNIOS> excessive amniotic fluid (more than

2,000 ml)
OLIGOHYDRAMNIOS > reduction of amniotic fluid ( less than 300 ml)

UMBILICAL CORD /FUNIS > extends from fetus to the center of placenta
> formed from the amnion & chorion & ppprovides
a circulatory connecting the embryo to the chorionic

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villi, spiraling or twisting

> transports O2 & nutrients to the fetus from
> the baby’s u-cord will fall off 7-10 days after delivery
> 50-53 cm (18-21 inches) long and 1-2 cm (1/2 inch) in
> 32 cm considered abnormally short

Contains 2 arteries & 1 vein:

Arteries > carry deoxygenated blood & fetal waste from the fetus to
placental villi
Vein > carries oxygen & nutrition from placental villi to fetus
WHARTON’S JELLY > protects umbilical vessels from pressure, cord kinking &
interference w/ fetal-placental circulation
> the 3 vessels of umbilical cord are characterized by “spiraling”
or twisting (dextral direction)
- serves to alternate from “snarling”
What to watch out for:
If the cord doesn’t fall off in 2 weeks time
The cord smells bad
There is drainage from the bottom of the cord
There is a red area on the skin around the bottom of the cord
If the newborn develops fever or app4ears unwell
If the navel and surrounding area becomes swollen or red
If pus appears at the base of the stump

PREGNANCY >normal physiologic process , 280 days/ 142 weeks
>9 calendar months / 10 lunar months

Subsequent prenatal visit assessment:

1st 28 wks. / 7 months. > every 4 weeks

From 7-9 months/ 28-36 wks.> every 2 weeks until delivery


1.5 lbs. > 1st 10 weeks
9 lbs. > 20 weeks
19 lbs. > 30 weeks
27.5 lbs. > 40 weeks
24-30 lbs. > average weight gain during pregnancy

Physiologic changes . characterized as local changes and systemic changes

Local changes / reproductive system changes
> vagina, uterus, cervix, ovaries, breast
Breast > first physiologic changes
Systemic changes > affecting the entire body


1. CHADWICKS’ SIGN > due to increase vascularization of the
vagina causes a blue-purple discoloration
2. VAGINAL SECRETIONS > fall from a ph of over 7
(alkaline) to 4-5 ph (acidic)
3. CANDIDA ALBICANS > a species of yeast-like fungi,
manifested by itching, burning sensation in addition to cheese-like

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4. THRUSH OR ORAL MONILIA > candidal infection

in newborn

B.UTERUS CHANGES >hegar’s sign, ballottement, Braxton hick’s, amenorrhea, weight

increases from 50 – 1,000 grams


12TH WKS. OF PREGNANCY > under the abdominal wall just above the
symphysis pubis
16th WKS. OF PREGNANCY> palpated bet. the symphysis pubis & umbilicus
20-22 WKS. OF PREGNANCY> palpated & reach the level of the umbilicus
36 WKS. OF PREGNANCY > to be palpated & touch the xiphoid process


1. OPERCULUM > mucous plug before the onset of labor

> seals the endocervical canal & prevents the
contamination of the uterus by bacteria

D. OVARIAN CHANGES > ovulation stops

> corpus luteum takes place 2 months
> placenta take over as the chief provider of progesterone
and estrogen and to provide for the growing fetus

E. BREAST CHANGES > Montgomery’s tubercles

> colostrum may leak of be expressed from the breast as early as
16th week of pregnancy
> may experience feeling of fullness, tingling sensation &
> areola & nipples darken in color


Fetal skull – is the largest anatomical pary of the fetus through the birth canal, usually if the head can
pass, the rest of the body can be delivered

Consists of 7 bones
2 frontal – presenting part
2 parietal – presenting part
2 temporal – not a presenting part
1 occipital
Suture lines of the skull
1. Sagittal suture – a membranous interspace, joins the 2 parietal bones of the skull
2. Coronal suture – is the line of the junction of the frontal bones and the 2 parietal bones
3. Lambdoidal suture – is the line of junction of the occipital bone and the 2 parietal bones
Closed – anterior fontanelle (diamond)
12-18 months posterior fontanelle (triangular)

1. Anterior fontanelle (Bregma)
- is at the junction of the 2 parietal bones and the two fused frontal bones
- diamond-shaped
- normally closes at age 12-18 months
measures 2 cm to 3 cm and 3 cm to 4 cm in length
2. Posterior fontanelle
- is at the junction of the parietal bones, and occipital bones
- normally closes by age of 2 months

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- measures approximately 2 cm across its widest part

- denotes the body parts that will first contact the cervix or deliver first
- determined by fetal lie, or the degree of flexion or the attitude or habitus
3 Types of fetal presentation
1. Cephalic presentation – means that the head is the body part that 1st contacts the cervix and
it is the most frequent type of presentation
4 Types of Cephalic Presentation
1. Vertex – head is sharply flexed, making the parietal bones or the space
between the fontanelles and the presenting part
2. Brow – head moderately flexed, the presenting part is the brow
3. face – head is extended, presenting part is the face
4. sinciput – the head is completely hyperextended, the head is nor flexed,
the presenting part is the sinciput

2. Breech presentation - means either the buttocks or feet are the first body parts to contact
the cervix
3 Types of breech presentation
1. Complete – thighs tightly flexed on the abdomen, the presenting part are
both the buttocks and tightly flexed feet
2. Frank – the hips are flexed but the knees are extended to rest on the
chest, the presenting part is the buttocks alone.
3. Footling – (incomplete breech presentation) neither the thigh nor the
lower legs are flexed, presenting part is the foot
- single footling breech – one foot is present
- double footling breech – both feet is present

3. Shoulder presentation - fetus is lying horizontally in the pelvis so that its long axis is
perpendicular to that of the mother, presenting part is the shoulder

acromion process – iliac crest, elbow, hand


- term used to describe the degree of flexion the fetus assumes or the relation of fetal parts to
each other

Four types
1. Complete flexion (normal fetal position)
- the spinal column is bowed forward, the head is flexed forward, the chin touches the
sternum, arms are flexed and folded on the chest, thighs are flexed on the abdomen and the
calves of the legs are pressed against the posterior aspect of the thighs
2. Moderate flexion (military position) sinciput
- the chin is not touching the chest (frank, sinciput)
3. Partial extension (brow presentation)
- presents the brow of the head to the birth canal
4. Complete extension (face presentation/incomplete footling)
- presents the face and the back is arched, the neck is entended
- is the relationship between the long axis of the featl body and the long axis of the woman’s
1. Transverse lie – fetus is lying horizonally. Ex. Shoulder presentation
2. Longitudinal lie – fetus is lying vertically

- is the relationship of the fetal presenting part to the maternal bony pelvis
- is determined by locating the presenting part in relation to the pelvis

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Means of assessing fetal position

1. Leopold’s maneuver – method of palpating the maternal abdomen to determine
information about the fetus such as presentation, engagement and rough estimate of fetal size
2. Vaginal examination
3. Auscultation of FHT
4. Sonography – diagnostic tool that is helpful in assessing a fetus for general size and
structural disorders or internal organs and limbs

6 Most Common Fetal Positions

1. LOP – FHT heard in LLQ
2. LOT – LLQ
3. LOA – LLQ
4. ROP – RLQ
5. ROT – RLQ
6. ROA – RLQ

Most Common Fetal Position

1. Left occipito anterior (LOA)
- occiput of the fetus points to the left side of the maternal pelvis and towards front,
face down
2. left occipito posterior (LOP)
- occiput of the fetus points to the left side of the maternal pelvis and towards rear
or face up
3. Left occipito transverse
- occipot of the fetus is parallel to the left maternal pelvis
4. Right occipito anterior
- occiput of the fetus points to the right side of the maternal pelvis, towards front
face down
5. right occipito posterior
- occiput of the fetus points to the right side of the maternal pelvis and toward the
rear or face up
6. Right occipito transverse (ROT)
- occiput of the fetus is parallel to the right maternal pelvis

Position measured in numeric terms:

Station- is the relationship of the presenting part of the fetus to the level of the ischial spines
0 station – presenting part is at the level of the ischial spines (engagement)
-1 to –4 cm – presenting part is above the ischial spines
+1 to +4 cm – presenting part is below the ischial spines
+3 to +4 cm – presenting part is at the perineum (crowning)

Other terms to denote station:

High – presenting part not engaged
Floating – presenting part freely moveable in inlet
Dipping – entering pelvis
Fixed – no lnger moveable in inlet but not engaged
Engaged – bipareital plane is passed through the pelvic inlet

- refer to the settling of the presenting part of the fetus (midpoint of the pelvis)
- largest diameter / widest diameter of the presenting part
- usually take place two weeks before labor
- maybe assessed by Leopold’s maneuver, vaginal / rectal examination / cervical examination

CERVICAL CHANGES: Two major signs

a. Effacement – shortening and thinning of the cervical canal
b. Dilatation – is the enlargement of the cervical cananl
- there is an increase in the amount of vaginal secretions

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1. Increment – when the intensity of the contractions increase
2. Acme – when the contraction is at its strongest peak
3. Decrement – when the intensity of the contraction decreases

Assesment of uterine contraction (power)

1. frequency – time from beginning of one contraction to the beginning of the next
2. Duration – time from the beginning of contraction to its relaxation
3. Strength (Intensity) – resistance to indentation
L – 20-24 sec 3-5 minutes
A – 40 – 60 sec
T – 60 – 90 sec 2-3 minutes

Labor – rhythmic cervical contractions

Labor normally begins 2 weeks prior or after EDC

Average normal labor 12 – 14 hours

Subsequent labor 6-8 hours shorter

Parturient – a woman in labor

Puerpera – woman who has just given birth
Puerperium – post-partum client

NSD (normal spontaneous delivery)

- Spontaneous in onset, low risk at the start of labor and remaining throughout the labor and
delivery. Infant is born whether cephalic or breech or in longitudinal lie.
- The infant is born between 38 to 40 weeks gestation. After birth, the mother and the infant
are in good condition and not having any complications.


a. 1st stage of labor – pain visceral caused by dilatation of the cerviz and uterine ischemia
visceral – pain refer to abdomen
b. 2nd stage of labor – pain is somatic (pain from back to the abdomen
- caused by hypoxia of the uterus, distention of the vagina and perineum, and pressure on adjacent
c. 3rd stage of labor – pain is similar in origin to that of the 1st stage of labor

WARNING SIGNS during labor

1. Contraction – hypertonic, poor relaxation or titanic

(>90 seconds long and <2 minutes apart)

2. Abdominal pain – sharp, rigid abdomen or boardlike abdomen and shock

3. Vaginal bleeding – profuse, marked vaginal bleeding
4. Normal FHT – 120 to 160 bpm
FHR periodic pattern decelerations
FHR – late decelerations, prolonged variable decelerations, bradycardia, tachycardia
Decelerations – periodic decrease of featl heart rate
5. Maternal Hypertension –

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PIH – pregnancy induced hypertension

- preeclampsia
- eclampsia
6. Meconium-stained amniotic fluid (MSAF)
7. Prolonged rupture of membrane (PROM)

a. Intra-partum care
- refer to the medical and nursing care given to a pregnant woman and her family during labor
and delivery

Intra-partum period
- extends from the beginning of contractions that cause cervical dilatation to the 1st 1-4 hours
after delivery of the newborn and placenta
Labor / parturition
- is the process by which the fetus and products of conception are expelled as the result of the
regular, progressive and strong uterine contractions
- is the last few hours of human pregnancy characterized by thunderous uterine contractions
that affect dilatation of the cervix and the force of the fetus through the birth canal
- myometrial contractions of labor are painful that is why pains is used to describe labor

B. Factors affecting labor / components of labor

1. passageway – refers to the adequacy of the pelvis and birth canal in allowing fetal descent
Factors include:
a. type of pelvis
b. structure of pelvis
c. pelvic inlet diameters
d. pelvic outlet diameters
e. ability of the uterine segment to distend the cervix and dilate and the vaginal canal
and introitus to distend

2. passenger – refers to the fetus and its ability to move through the passageway which is
based on the following:
a. size of the fetal head
b. fetal presentation
c. fetal attitude
d. fetal position

3. power – refers to the frequency, duration, strength of uterine contractions to cause

complete cervical effacement and dilatation

4. placental factors – refers to the site of placental insertion

5. Psyche – refers to the client’s psychological state, available support system, preparation for
childbirth, experiences and coping strategies

C. Signs and symptoms of impending labor / premonitory signs of labor

1. Lightening – is the descent of the fetus and uterus into the pelvic cavity 2-3 weeks before
the onset of labor
2. Braxton Hicks contractions are irregular, intermittent contractions that have occurred
throughout the pregnancy, becomes uncomfortable and produce a drawing
pain in the abdomen groin
3. Cervical changes include softening, ripening and effacement of the cervix that will cause
expulsion of the mucous plug (bloody show)
4. Rupture of amniotic membranes may occur before the onset of labor. If the woman
suspects that her membranes have ruptured, she should contact her OB-
Gyne and go to the labor suite immediately so that she may be examined
for prolapsed cord – a threatening condition for the fetus
* Premature rupture of membranes

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5. Burst of energy or increased tension and fatigue may occur right before the onset of labor
6. Weight loss of about 1 – 3 lbs may occur 2-3 days before the onset of labor

Characteristics of false labor

1. Contractions are irregular, occur at irregular intervals – decreased frequency and intensity,
longer intervals between contractions
2. contractions located chiefly in the abdomen
- intensity remains the same or variable
- intervals remain long
3. Walking does not intensify contractions and often gives relief
- either no effect or decreases contractions
4. “bloody show” usually not present. If present, usually brownish in color
5. There is no cervical changes
6. Contractions disappear while sleeping
7. Sedation decreases or stops contractions
8. Discomfort in lower abdomen and groin
Characteristics of true labor
1. Contractions occur at regular intervals
2. Contractions start at the back and sweep around to the abdomen
- increased intensity and duration or progressive
- shortened intervals between contractions
3. Walking (activity) intensifies contractions
4. “Bloody show” present (pink-tinged mucus released from the cervical canal and as labor
5. Contractions continue while sleeping
6. Cervix becomes effaced and dilated.
-progressive thinning and opening of the cervix
7. Sedation does not stop contractions
8. Discomfort begins in the back and radiates to the abdomen

Length of labor

a. 1st stage
nullipara – 8-12 hrs
multipara 6-8 hrs

b. 2nd stage
nullipara 1-2 hrs
multipara 30 minutes

C. 3rd stage
nullipara 5-60 minutes
multipara 5-60 minutes

Separation of placenta – 5 to 6 minutes

Cardinal movements of normal delivery (DFIERE)

1. descent
2. flexion
3. internation rotation
4. extention
5. restitution (external rotation)
6. expulsion


1. 1st stage of labor

- begins with the onset of regular contractions which cause progressive cervical dilatations
and effacement and it ends when the cervix is completely effaced and dilated

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N.A. – due vaginal examination to detect if there is cervical dilatation

- frequency of vaginal exam: once every 4 hours

3 Phases of the 1st stage of labor

a. Latent phase – this phase begins with the onset of regular contractions and effacement and
dilatation of the cervix to 1 to 3 cms. Contractions become increasingly stronger, shortened
and more frequent lasting for abour 20 to 40 seconds occurring approximately 3-5 minutes
- walking is recommended
- effacement and dilatation 1 to 3 cm
- contractions last for 20-40 seconds (duration)
- contraction interval 3-5 minutes (frequency)

b. Active phase
- dilatation from 4 – 7 cm
-contractions lasts 40 – 60 seconds
- contractions becomes stronger, more frequent, longer and more painful

c. Transition phase
- the culmination of the 1st stage of labor is the transition phase during which the cervix
dilates from 8 to 10 cm
- intensity, frequency and duration of contractions peak and there is an irresistible urge to
push lasting for about 60-90 seconds
-dilatation 8-10 cm
- contractions lasts 60-90 seconds
-intervals of 2-3 minutes

2. 2nd stage of labor (expulsive stage, including episiotomy)

- this phase begins with the complete dilatation of the cervix and ends with delivery of the
-woman feels the urge to bear down

a. contractions are severe at 2-3 minutes intervals, with a duration of 50 seconds or less
- membranes rupture spontaneously
b. newborn exits into the birth canal with the help of the mechanism of normal labor or
cardinal movements
c. “crowning” occurs when the newborn’s head or presenting part appears at the vaginal
d. Episiotomy – surgincal incision of the perineum, may be done to facilitate delivery and
avoid laceration of the perineum
e. Clamping the umbilical cord. The cord is but between 2 clamps placed 4 to 5 cms from
the fetal abdomen and later on an umbilical cord clamp is applied 2-3 cm from the
fetal abdomen


1. Descent – 1st requisite for birth of the infant, brought about by one or more four forces:
a. pressure of the amniotic fluid
b. direct pressure of the fundus upon the breech
c. contraction of the abdominal muscles
d. extension and straightening of the fetal body

2. Flexion – a movement which the chin is broight about into more intimate contact with the
fetal thorax

3. Internal rotation – turning of the head in such a manner that the occiput gradually moves
from its original position anteriorly toward the symphysis pubis

4. Extension – back of neck pivots under s.p. allows head to be born by extension

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5. Restitution (external rotation) – head returns to normal alignment with shoulders, presents
smallest diameter of shoulders to outlet

6. Expulsion – borth of neonate completed (3rd stage)

EPISIOTOMY – a surgical procedure or an incision performed to facilitate the delivery of the


1. surgical incisions reduces laceration
2. heals more easily than lacerations
3. protects infants head from pressure exterted by resistance
4. protect infants from signs of fetal distress
5. gives sufficient progress of delivery
6. shortens the 2nd stage of labor

Side effects of episiotomy

1. infections
2. longer healing time

Types / degree of lacerations / perineal tear / birth canal

1. 1st degree – involves the fourchette, perineal skin and vaginal mucous membrane but not
the underlying faschia and muscle

2. 2nd degree – skin and mucous membrane, the faschia and muscle of the pernial body but
not the rectal spinchter thus forming triangular injury, usually can be sutured under local

3. 3rd degree – extends to the skin, mucous membrane and perineal body and involved the
anal spinchter can be sutured by an expert obstetrician. Complications: fecal incontinence and

4. 4th degree – extends to the rectal mucosa to expose the lumen of the rectum and it bleeds

Health teachings

1. cold packs to the perineum

2. sitz bath
3. using medication

Two types of episiotomy

1. Midline
2. Mediolateral

Characteristics Midline Mediolateral
1. surgical repair easy more difficult
2. faulty healing rare more common
3. post-operative pain minimal common
4. anatomical results excellent occasionally faulty
5. blood loss less more
6. dyspareunia rare occasional
7. extensions common* uncommon
* only disadvantage of midline


1. ensure patent airway

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2. suction with bulb syringe

3. maintain body tempterature
4. identify infant
5. prevent eye infection
6. facilitate prompt identification
7. intervention in hemolytic problems of the newborn (vit. K)

3. 3rd Stage of labor “Placental Stage”

- this phase begins with the delivery of the newborn and ends with the delivery of the placenta. Some
bleeding is inevitable during this stage. It occurs in two phases
- 5-6 minutes gap before placenta comes out
- order oxytocin 10 in (IM) or IV push
- increased blood loss if placenta comes out after 30 minutes

a) Signs of placental separation

1. Uterus becomes globular or firmer. It is the earliest sign to appear.
“Calkin’s Sign”
2. Sudden gush of blood from the vagina
3. Lengthening of the imbilical cord, 1-5 minutes after delivery of the infant
4. Fundus rises up in the abdomen

b) Placental expulsion
1. Placenta is deliver by natural bearing down effort of the mother
2. Crede’s maneuver is performed by the doctor or nurse by gentle pressure over the
contracted uterine fundus
3. Duncan placenta / mechanism – as the placenta separates, the blood from the
implantation site may escape into the vagina immediately. It looks raw and red in
- edges, meaty, everted, maternal side

Hysterectomy – 3,000 – 3,500 ml blood loss

4. Schultze’s placenta / mechanism – concealed behind the placenta and membranes

until the placenta is delivered, appears shiny and glistening from the fetal
membranes (fetal side)
-NSD blodd loss = 500 ml to less than 1,00 ml
-CS blood loss = 1,000 ml to 1,400 ml

4. 4th stage of labor (recovery or bonding stage)

a. This stage lasts from 1-4 hours after birth of the newborn
b. The mother and newborn recover from the physical process of birth
c. The maternal organs undergo initial readjustment to the nonpregnant state
d. The newborn body systems begin to adjust to extrauterine life and stabilize
e. The uterus contracts in the midline of the abdomen with the fundus midway between the
umbilicus and symphysis pubis


1. Provide pain relief for afterpains
2. Relieve muscular aches
3. Give episiotomy care
4. Promote perneal exercises
5. Administer sitz bath
6. Provide perineal care
7. Promote perineal self-care

Postpartum warning signs to report to the physician

1. Increased bleeding, clots or passage of tissue
2. bright red vaginal bleeding anytime after birth

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3. pain greater than expected

4. temperature elevation to 110.4 F
5. Feeling of full bladder accompanied by inability to void
6. enlarging hematoma
7 feeling restless
8. pain, redness and warmth accompanied by a firm area in the calf
9. difficulty breathing, rapid HR, chest pain, cough, feeling of apprehension, pale, cold blue
or blue skin color

Postpartum sexual activity

1. sexual intercourse may be resumed at 2-3 weeks after birth
2. Sexual intercourse should not resume until vaginal bleeding has stopped and the
episiotomy has healed
3. sexual arousal may cause milk to leak from the breast
4 longer periods of foreplay will encourage lubrication
5. when the infant is weaned from the breast, sex drive will usually return to normal
6.the contraceptive meethid of choice should be used as directed, at the initiation of sexual

APGAR score: Newborn assessment

A = appearance > color
P = pulse > heart rate
G = grimace > reflex irritability to a gentle slap
A = activity > muscle tone
R = respiratory effort

Points of status : APGAR

- Good = 7 to 10
- Fair = 4 to 6
- Needs resuscitation = 0 to 3

APGAR scoring chart

Sign 0 1 2
Heart rate absent slow (<100) > 100
Respiratory effort absent slow, irregular weak cry good, strong
Muscle tone flaccid some flexion of extremities well flexed
Reflex no response grimace cough,
sneeze, cry
of foot
Color blue, pale body pink, extremities blue completely

- periodic decrease of featl heart rate (FHR)
- normal FHR is 120 to 160 bpm

Three types of Decelerations

1. early decelerations
- FHR begins to slow with the onset of the uterine contractions and returns to
baseline when contractions are over (drop to 100 bpm but not lower)
- indicates Fetal Head Compression (FHC)
- no nursing intervention is needed, continue observation
2. Late Decelerations

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- FHR begins to fall and the height of UC and returns to baseline after contraction
has ceased
- 70 bpm
- indicates Utero Placental Insufficiency (not enough supply from the placenta)
3. Variable Deceleration
- abrupt transitory decrease of FHR
- indicates Umbilical Cord Compression (UCC)

Nursing Interventions
1. Change maternal position to the left
2. turn off pitocin (oxytocin)
3. begin 02 mask @ 8-10 L/min
4. check BP & PR
5. possible candidate for CS
****** Interventions for Late deceleration
6. observe perineum for blob show & appearance of amniotic fluid
7. assess for fetal distress
8. assess for bright red vaginal discharge / bleeding
***** interventions for variable deceleration


a. assessment
- mucus in nasopharynx, oropharynx
- note and record apgar score
- # of vessels in the umbilical stump
- passage of meconium stool, urine
- general physical appearance
b. analysis / ND
1 ineffective airway clearance related to excessive nasopharyngeal mucus
2. ineffective breathing pattern related to CNS depression secondary to intrauterine
hypoxia and prematurity
3. impaired gas exchange related to respiratory distress
4. fluid volume deficit related to birth trauma, hemolytic jaundice
5. impaired skin integrity related to cord stump
6. high risk for injury related to impaired thermoregulation (incubation & drop light)
7. ineffective thermoregulation related to environmental condition

c. NCP / implementation
- ensure patent airway
- suction with bulb syringe
- maintain body temp
- identify infant
- prevent eye infection
- facilitate prompt identification / vigilance for potential neonatal complications
1. history of pregnancy
2. history of delivery
- facilitate prompt identification / intervention in hemolutic problems of the newborn


a. assessment
- every 15 minutes, 4 times, then every 30 minutes, 2 times or until stable
- to monitor response to physiologic stress of labor / birth
1. vital signs
2. location and tone of fundus
- midline
- firm & slightly lower than the umbilicus
3. perineum – edema / rectal pain

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4. bladder – initial nursing action is to alternate warm & cold packs

- fullness of bladder
5. rate of IV, I&O
6. interactions between parents, newborn, signs of bonding
7. assess for signs of postpartal emergencies
- hemorrhage
- uterine atony
Nursing care plan
- comfort measures
1. maternal position – supine
2. pad change
3. perineal care
4. ice pack to perineum as ordered

- nutritional hydration – offer oral fluid, 4-6 hours

-urinary elimination
- promote bonding
- health teachings
- signs to report to physician
1. uterine cramps
2. increased vaginal bleeding, passage of large clots
3. nausea, dizziness
(Kegel exercise – eliminate urination)
4. pain greater than expected
5. temp elevation at 110.4 F
6. enlarging hematoma
7. feeling of full bladder accompanied by inability to void

POSTPARTUM (puerperium)
- six weeks after delivery or beginning with the termination of labor and ending with the
return of the reproductive organ to its non-pregnant state
- sometimes called as “4th trimester of pregnancy”

Uterus – contracts firmly, reducing its size by more than half

Lochia – discharge from the uterus during the first 3 weeks of delivery

3 types of lochia = “RSA”

1. Lochia rubra
color – dark red
duration – 1-3 days after delivery
composition – blood, epithetial cells, erythrocytes, leukocytes & fragments
of decidus
odor – characteristic odor
2. locahia serosa
color – pinkish to brownish
duration 3-10 days after delivery
composition – blood, decidus, erythrocytes, leukocytes, cervical mucus &
odor – strong odor
3. lochia alba
color – colorless to creamy yellowish
duration – 10 days to 3 weeks after
composition – leukocytes, decidus, epithelial cells, fat, cervical mucus,
cholesterol crystals & bacteria
odor – no odor

Fundal height & consistency after delivery

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1. after birth / delivery

- fundus is palpated halfway between the umbilicus & symphysis pubis, or
@ the level of the umbilicus, size & consistency of firm grapefruit
2. day 1 (first 12 hours)
- one firngerbreath (1 cm) below the umbilicus
3. descends by 1 fingerbreath daily until day 10
4. day 10 to 14
- palpated behind symphysis pubis, non-palpable abdominally
5. 4-6 weeks
- returns to its non-pregnant size

6. 6-7 weeks
- to heal site of placental attachment

GOALS of post-partum care

1 promote normal involution & return to the non-pregnant state
- involution of the uterus – pregressive changes of the uterus after delivery
2. prevent or minimize post partum complications
- profuse bleeding
-puerpera infection
- mastitis
- thrombophebitis
- sub-involution
3. promote comfort & healing of pelvic, perianal and pernienal tissues
4. assist in restoration of normal body function
5. increased understanding of physiologic & psychological changes
6. facilitate new born care & self-care of the mother
7. promote the new born’s successful integration into the family unit
8. support parenting skills & parent-newborn attachment
9. provide effective discharge planning including appropriate referral for home-care follow up

Post-partum psychological adaptation

By Reva Rubin

3 phases of puerperium
1. taking-in phase
2. taking-hold phase
3. letting go phase

Taking-in phase
- occurring 1-2 days after delivery
- time for reflection – talkative
- mother typically passive & dependent
- review her labor & delivery experience frequently

Taking-hold phase
- extending 2-4 days after delivery
- time for initiating action
- expressed little interest in caring for her child
- strives to master newborn care skills

Letting go phase
- this phase generally occirs after the new mother returns home
- time of family reorganization; time for a new role
- assumes responsibility for newborn care
- adapt to the demands of newborn dependency
- post partum depression most commonly occur during this phase

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Post partum depression

- a “let down” feeling after giving birth related to the magnitude of the birth
experience & doubts about the ability to cope effectively with the demands of
- begins 2-3 days after delivery & resolving pain within 1-2 weeks

Post-partum blues
- also known as “baby blues”
- due to hormonal changes
- evidenced by tearfulness, feelings of inadequacy, moody, anorexia & sleep
- serious depression, postpartal psychosis – requiring formal counseling or
psychiatric care

- the infant stays in the room with the mother rather than staying in the central

Two types of rooming-in

1. complete
- implies that the mother & the child are together 24 hours a day
2. partial
- in which the infant remains in the mother’s room for part of the

- voluntary prevention of pregnancy
- intentional prevention of conception through the use of various devices, agents, drugs, sexual
practice or synthetic products

- device, drug or chemical agent that prevents conception or acapbale of preventing

Factors to be considered in using and choosing contraceptives

1. religious orientation
2. social & cultural values
3. medical contraindication
4. psychological contraindication
5. individual sexual orientation
6. cost
7. availability of bathroom facilities and privacy
8. partners support and willingness to cooperate
9 personal lifestyle

* coitus interuptus (withdrawal) – least effective

* IUD – most effective
A. Assessment
1 determine interest and present knowledge of method of family planning
2. identify factors affecting choice of contraceptive method

b. ND
1. knowledge deficit regarding family planning methods

c. NCP
GOAL: health teachings to
1) facilitate informed decision-making;
2) selection of options appropriate to individual needs and desires

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Health teachings
1. describe, explain, discuss options available & appropriate to the woman, include
information on advanatagse and disadvanatages of each option
2. demonstrate as necessary method selected
3. quick health teachings – reminders for missed oral hormone preparations
a. 1 pill should be taken at the same time every day for 21 days
b. if woman misses 1 pill, she should take it as soon as she remembers it
and then take the next pill about the usual time
c. if woman missed 2 or more pills in a row, in the 1 st 2 weeks of her cycle,
she should take 2 pills for 2 days and use a backup method of
contraception for the next 7 days
d. Evaluation:
Woman avoids / achieves a pregnancy as desired

a. Hormonal contraceptives
1. Combination of estrogen and progesterone
- suppresses ovulation by suppressing production of FSH & LH
- most efficient form of contraception
- convenient, easy to take, withdrawal bleeding cycles are predictable
- not related to sex act, safe for older non-smoking women until menopause
- many contraceptives health benefits
1. absolute CI: thromboembolic, or CAD (coronary artery disease), some
cancer (CA) and liver disease
2. relative CI: migraines, HPN, abnormal genital bleeding, immobility
3. no protection against STD
4. effectiveness decreased during use of barbiturates, phenotoin, antibiotics
5. some decrease in glucose tolerance

2. Estrogen only = “morning-after pill”

action of estrogen
- anti-feritlity: taken within 72 hours of unprotected coitus during fertile
- available, PRN
- because of DES effect on fetus, elective abortion advised if method fails
DES = diethylstilbestrol

3. Progestin only – “minipill, depo-provera, norplant”

- impairs fertility, thickens cervical mucus, decreases sperm penetration
- alters endometrial maturation
- effectiveness: undertermined, can reach 100% reliability if used exactly
- (O) convenient, easy to take
-(IM) 2-4 times/ year. Lactation ok during this time
- subdermal
- not related to sex act
- ovulation may occur
- irregular bleeding
- may change glucose and insulin values
- no protection against STD

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B. Intrauterine devices (IUDs)

- small T-Shapaed device inserted into uterine cavity medicated with copper and

- prevents fertility: damages sperm in-transit to the fallopian tube
- effectiveness: 90-99%
- can be used by women who cannot use hormonal contraceptives
- no disruption of ovulation pattern
- less blood loss during menses and decreased primary dysmenorrheal
- copper can be used effectively for 10 years; progesterone: yearly
- Hx of PID (pelvic inflammatory disease), pregnancy, unDx genital
bleeding, genital malignancy, ANG
- uterine perforation, infection
- heavy flow, spotting between periods, cramping within few months of
- must check for string after each menses and before intercourse
- no protection against STDs

C. Mechanical barriers
1. Diaphragm
- shallow rubber device that fits over cervix

- barrier preventing sperm from entering cervix
- effectiveness: 83-90%, 99% in highly motivated women
- does not interrupt sex act
- insert 6 hours before intercourse and leave in place for 6 hours after last
- no SE from well-fitted device
- decreased incidence of vaginitis, cervicitis, PID
- require careful cleansing with warm water and mild soap
- size/fit needs to be checked after term birth, and or 3rd trimester abortion,
weight gain or loss of 20 lbs or more
- spermicide must be inserted for additional acts that may follow initial
- no protection against STDs

2. Cervical cap
- 1 ¼ - 1 ½ in soft, natural rubber dome with a firm but pliable rim

- physical barrier to sperm
- spermicide inside cap adds a chemical barrier
- effectiveness: same with diaphragm
- worn for 8 hours but not longer than 48 hours
- no need to add spermicide for repeated acts of intercourse
- needs a yearly papsmear
- if in place for over 48 hours it produces an odor
- cannot be worn during menstrual flow (menses) or up to 6 weeks
- CI abnormal papsmear, hard to fit, genital infection, allergy
- must be checked regularly

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- no protection against STDs

3. Female condom
- vaginal sheath of natural latex rubber with flexible rings at both the closed and the
open areas

- barrier preventing sperm from entering the vagina
- effectiveness: similar to other mechanical methods used with spermicide
note: male and female condoms should not be used at the same time
- apply well in advance of intercourse, spermicide added just before sex
- heightens sensation for man
- about as satisfying for both woman and man as intercourse without it
- provides protection from STDs
- cost is high
- a new one must be used for every act of intercourse

4. Male condom
- thin, stretchable latex sheath to cover penis

- barrier preventing sperm from entering vagina
- applied over erected penis before loss of preejaculatory drops
- spermicidal foan or jelly or cream is also used
- effectiveness: 64-98% when used with spermicide

- increased effectiveness of mechanical barriers
- ease of application
- aids in the lubrication of the vagina
- requires no medical exam or Rx
- maybe used during lactation
- backup for missed or oral contraceptive pills
- may provide some protection from STDs
- messy
- some people are allergic to preparations
- tablets/suppositories take 10-15 mins to dissolve
- if it is the method being used, each intercourse should be preceded (by 30
mins) by a fresh application

E. Other methods

1. Calendar method (rhythm)

- recommended for women with regular menses
- 9 days
- this method relies on abstinence from sexual intercourse during fertile
- pregnancy is prevented by not having coitus during the unsafe fertile
- effectiveness: 80%
- requires a fairly predictable menstrual cycle
- requires knowledhe of cycle lengths, fairly predicatble menstrual cycle
and formula
- effectiveness depends on high level of motivation and diligence
- no protection against STDs

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- research 8-10 months if cycle is normal

2. Basal body temperature (BBT)

- measured by taking and recording the temp orally or rectally each
morning before rising
0.4 to 0.8 F = increase during ovulation

3. Cervical mucus method (CMM)

- uses the appearance, characterisitic and amount of cv to identify ovulation
- during ovulation = appearance of cv is clear and slippery, more abundant
- after ovulation = cv is yellowish and thick in characteristic, less abundant

4. Symptothermal method
- combination of BBT and CMM

- more complex and difficult to learn and requiring regular and daily effort

5. Mittleschmerz
- pain experienced by women in between menstrual cycle (time when the
ovary releases eggs)
- rarely, the pain may be accompanied by discharge

6 Coitus interruptus
- requires withdrawal of the penis from the vagina before ejaculation

- highly ineffective because sperm exists in pre-ejaculatory fluid
- unreliable, interrupts sexual excitation or the plateau phase and diminishes

ALERT TO DISCONTINUE the use of oral contraceptive

Signs and symptoms of potential problems = “ACHES”

A = abdominal pain:possible problem with liver or gallbladder
C = chect pain or shortness of breath, possible clot problems w/in the lungs
or heart
H = headaches (sudden or persisitent) possible caused by CVA (cerebro
vascular accident or HPN)
E = eye problem : possible cause by CVA or HPN
S = severe leg pain: possible thromboembolic process

ALERT woman of signs of potential problems related to IUD = “PAINS”

P = period (menstrual) late, abnormal clotting, spotting or bleeding
A = abdominal pain, pain with coitus (dyspareunia)
I = infection, abnormal vaginal discharge
N = not feeling well, fever or chills
S = string is missing (non-palpable on vaginal self-exam) or not seen on
speculum exam

Toxic Shock Syndrome (TSS)

Alert woman of signs of TSS = “FHRSC”

F = fever of sudden onset (over 38.9C or 102 F)
H = hypotension – systolic pressure (less or equal) 90 mmHg or orthostatic
dizziness, disorientation
R = rash, diffuse, macular,, erythroderma (resembling sunburn)
S = sore throat, sever nausea, vomiting
C – copius vaginal discharge

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- is a systematic abdominal palpation of the pregnant woman to determine position and presentation of
the fetus. It is done by about 32 weeks and over. The nurse should develop skills related to

1. explain the procedure to the client

- 1st nursing intervention in any procedure
- assures the mother, allays anxiety and gain maternal cooperation
2. instruct the client to empty the bladder if full
- the bladder lies anterior to the uterus
- means abdominal discomfort if the bladder is full
- to get the desired results esp for M. 3&4
3. position client in a supine position
- to be comfortable
4. drape client for privacy
5. wash hands, warm hands by briskly rubbing each other before placing them on the abdomen
- prevents tension and hardening of abdominal muscles
6. palpate gently:

1st maneuver
- outline the contour of the uterus
- ascertain how nearly the fundus approaches the xyphoid process
- palpates the fundus with tips of fingers of both hands to define which fetal pole is present
a. normal: if buttocks, soft, nodular body, non-ballotable
b. breech: head, hard, round, ballottable

2nd maneuver
- put palms on either side of the abdomen
- gentle but deep pressure is exerted
- palpates the sides to detect location of fetal back and fetal small parts
a. back: hard, resistant structure, smooth
* best site for auscultation
b. small parts: numerous small, irregular, nodular with bony prominences, mobile

3rd maneuver
- using the thumb and fingers of one hand, the nurse grasps the lower portion of the maternal
abdomen, just above the symphysis publis
- to detect if the presenting part is engaged or not engaged
a. if not engaged: get the attitude of the head
- cephalic prominence same side with the small parts
- is the head is flexed, vertex presenting
- if same side with the back, head is extended
- moveable body
b. if deeply engaged
- the lower pole of the fetus is fixed in the pelvis

4th maneuver
- face the mother’s feet
- with the tips of 1st fingers of each hand, exert deep pressure in the direction of the axis of the
pelvic inlet
- to detect degree of flexion, position and station
a. if head presents: one hand is arrested sooner than the other by a rounded body, the
cephalic prominence, while the other hand descend more deeply into the
b. vertex: same side as the back

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1. spontaneous abortion
2. gestational trophoblastic disease (hydatidiform mole)
3. ectopic pregnancy
4. incompetent cervix
5. hyperemesis gravidarum
6. placenta previa
7. abruption placentae
8. pregnancy-induced hypertension (PIH)

Most common causes of bleeding:

1st trimester = spontaneous abortion, ectopic pregnancy

2nd trimester = gestational trophoblastic disease, incompetent cervix
3rd trimester = placenta previa, abruptio placenta

1. Spontaneous abortion (miscarriage)
- expulsion of the feyus and other products of conception from the uterus before the fetus is
- the termination of pregnancy before 20 weeks based upon the date of the 1 st day of the last
normal menses
- the delivery of the fetus-neonate that weigh less than 500 grams (2,500 – 4,250 grams

* products of conception
1. fetus
2. membranes (amniotic membranes)
3. placenta
etiology and pathophysiology
- spontaneous abortion may result from unidentified natural causes from fetal,
placental or maternal factors

A. fetal factors (most frequent cause of spontaneous abortion)

-defective embryogic development
* most morphological finding in early spontaneous abortion or
“blighted ova” – macerated ova (half of the body is absent)
- faulty ovum implantation
- rejection of the ovum by the endometrium
- chromosomal abnormalities
B. placental factors
- premature separation of the normally implanted placenta (abruption
- abnormal placental implantation (ectopic pregnancy)
- abnormal platelet function
C. maternal factors
- infection (measles, rubella)
- severe malnutrition
- reproductive system abnormalities
- endocrine problems (DM, hyperthyroidism)
- trauma (accidents)
- drug ingestion (tobacco, alcohol, marijuana)

* resumption of ovulation after abortion

- ovulation may resume as early as 2 weeks after abortion,
therefore, it is important that effective contraception be initiated
soon after abortion

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Types of spontaneous abortion

1. threatened abortion
2. inevitable / imminent abortion
3. incomplete abortion
4. complete abortion
5. missed abortion
6 . habitual / recurrent abortion

1. threatened abortion
- cramping and vaginal bleeding in early pregnancy
- abdominal pain
- slight bright red vaginal bleeding that persist for days or weeks
* coming from uterus of the mother
* minimal bleeding
- persistent low backache
- no cervical dilatation (closed)
- pregnancy test +
- it may subside or an incomplete abortion may follow
* 50% may subside
* 50% incomplete abortion may follow

Goal: Health teaching
- suggest to avoid coitus and orgasm to present the possibility of infection
and to avoid possibility inducing further bleeding
Case: if an IUD is still present and the string is visible:
- device should be removed
results in = late abortion
= sepsis
= preterm birth

Case: if string is not visible:

- no attempt to locate & remove the device
= abortion
= sepsis
= offered to an option of a pregnancy termination

2. Inevitable / imminent abortion

- sudden discharge of fluid, suggesting ruptured of membranes
- vaginal bleeding
* inevitable = moderate
* imminent = profuse
-cramping abdominal pain
- fever
- urge to bear down
- cervix is dilated (open)
- termination cannot be prevented
- PT +
- nitrazine test +
= ruptured amniotic fluid
= dark blue in color

3. Incomplete abortion
- expulsion of only one part of the products of conception
(fetus first, placenta and membranes likely to be expelled together
in abortion occurring before 10 weeks but separately thereafter)

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- vaginal bleeding is moderate (occurs with c.d)

- cervical dilatation

4. Complete abortion
- complete expulsion of all products of conception
- the entire products of conception are expelled spontaneously w/o any
- vaginal bleeding minimal
- cervical dilatation

5. Missed abortion
- defined as the retention of dead products of coneption in utero for several
weeks (4-6 weeks)
- early fetal intrauterine death w/o expulsion of the products of conception
- client may report dak brown vaginal discharge
- uterus seems to remain stationary in size
- fetal heart sound cannot be heard
- cervix is closed
- PT negative

Goal: safeguard status
- save all perineal pads, clots, tissue for expert Dx
- report STAT any changes in status, excessive bleeding, signs of
infection, shock
- prepare for surgey – dilatation & curettage (D&C)

Medical management
- endomterium scraped with metal curetter or flexible aspiration tip under
local anesthesia.
(paracervical block) procedure for 15 minutes
- replace blood loss, maintain IV fluid levels
- if pregnancy is over 14 weeks – labor may be induced by means
of prostaglandin / oxytocin to dilate cervix
- replace blood loss, maintain fluid levels with IV

6. Habitual / recurrent abortion

- 3 or more consecutive spontaneous abortion
- Hx of spontaneous loss of 3 or more successive progrnancy that occurred
and same gestation age in 3 pregnancies

- defective spermatozoa or ova
- endocrine factors – luteal phase defect
- deviations of the uterus
- infections
- autoimmune disorder
a. fluid volume deficit
b. anticipatory grieving
c. dysfunctional grieving
d. risk for infection
1. anorexia – loss of appetite
2. body malaise
3. headache

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4. mother complains of cramping in the lower abdominal region

5. there is vaginal bleeding

2. Gestational trophoblastic disease (GTD) – hydatidiform mole, molar pregnancy

- an alteration of early enryonic growth causing placental disruption, rapid proliferation of
abnormal cells and destruction of the embryo
- developmental anomally of the placenta that converts the chorionic villi into a mass of clear
vesicles (hydatid vessels)
- multiplication / degeneration / proliferation of trophoblastic villi (outer layer of blastocyst)
- prone to high-risk pregnancy

- the embryo dies and the trophoblastic cells continue to grow forming an
invasive tumor
* choriocarcinoma = because it produces an increase in HCG
= extremely malignant form of trphoblastic villi
- placental tumor that develops after pregnancy has occurred, a
hydatidiform mole maybe benign or malignant
- blood vessles are absent, as are the fetus & amniotic sac
- sperm enters empty egg and its chromosome replicate (complete) or
triplicate (incomplete)
- characterized by proliferation of placental villi that becomes edematous
and form “grapelike clusters” vesicle or “snowstorm”
- genetic abnormalities at the time of fertilization are thought to be
responsible for trophoblastic disease
- PT + or –
2 types of GTD
a. complete mole
- there’s neither an embryo nor an amniotic sac
- this phenomenon is referred to as “androgenesis”
- 46 xx chromosomes contributed by the paternal material
- karyotype = haploid sperm
b. partial more
- there is an embryo (multiple abnormalities) & an amniotic sac
- typically has stigma of triploidy which includes multiple
congenital malformation and growth restriction – it is
- karyotype – haploid findings
- 69 chromosomes from the father

1. severe nausea and vomiting = because of severe increase in
HCG due to the proliferation of trophoblastic villi
2. PIH before 20 weeks gestation (convulsion, edema)
3. vaginal bleeding
- brownish in color “prune juice”
- as early as 14 weeks or 3 months
4. uterus larger than expected for the duration of the pregnancy
5. inconsistent fundal height w/ gestational estimate
6. abdominal cramping from uterine distention
7. no fetal heart sounds will be heard
8. infection because te woman is at risk of a perforation of the
abdominal wall

associated findings
1. abnormal high serum levels of HCG
normal = 400,000 intl unit
abnormal 1-2 million intl unit

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2. characteristic appearance of molar growth on ultrasound tracing,

x-ray, sonogram can be detected
age: the most pronounced effect is seen in women over
45-50 yrs old
* in GTD, should not be pregnant in 1 year
Dx procedure
1. ultrasound – to see the appearance of the mole
= uterine myoma
= early pregnancy
= multiple pregnancy / fetus
Hysterectomy = if choriocarcinoma is present
Medical management
1. D&C to evacuate grapelike vesicles
2. hysterectomy – choriocarcinoma
3. suction curettage
1. monitor signs for PIH (preeclampsia & eclampsia)
2. strict contraception for at least 1 year to enable accurate
assessment of status (discuss contraceptive options)
3. observe for hemorrhage, passage of retained vesicles and
abdominal pain
4. explain. Discuss tests, prepare for tests
5. facilitate grieving
3. Ectopic pregnancy
- implanatation of products of conception in a site other than the endometrium
- implantation outside the uterine cavity or outside the uterus
- 1st trimester

4 types of ectopic pregnancy

1. fallopian tube (tubal) common site of EP
- 95%
- ampullar portion
2. cervix – 60%
3. abdomen – 25%
4. ovary – 5%

1. presence of IUD
2. tubal or uterine anomalies, tubal spasm
3. PID (pelvic inflammatory disease
4. 43% caused by STD
5. adhesion from PID of past surgeries
6. endometritis
7. use of progestin only
associated findings
1. early signs
- abnormal menstrual period
- vaginal bleeding
- spotting
- dizziness
2. impending or post-tubal upture
- sudden & acute, sharp lower abdominal pain
- nausea & vomiting
- signs of shock
* Kehr’s sign – referred to neck and shoulder-strap sharp pain, neck pain
due to the presence of blood in the peritoneal cavity
* Cullen’s sign – ecchymotic blueness of the umbilicus which is indicative
of hematoperitoneum
Medical management

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surgical removal repair (SRR)  unruptured ectopic pregnancy

if ruptured  laparatomy with surgical removal repair
probable ruptured ectopic pregnancy  ligate bleeding vessels & to remove
/ repair damaged fallopian tube
1. Anxiety
2. anticipating grief
3. knowledge deficit
4. pain
1. assess vital signs, bleeding & pain
2. explain the condition, describe self-care measures
3. offer emotional support as the client grieves for the lost baby

4. Incompetent cervix (dysfunctional cervix)

- cervical effacement & dilatation in early 2nd trimester resulting in expulsion of the products
of conception
- characterized by painless dilatation of cervical OS w/o contractions of the uterus

1. history of traumatic birth (abortions)
2. foreceful D&C / repeated D&C
3. client’s mother treated with DES when pregnancy with the client
4. congenitally small cervix
5. uterine anomalies
6. unknown etiology
1. show = pink-stained vaginal discharge
2. increased pelvic pressure
3. followed by rupture of membrane
4. discharged of amniotic fluid
5. expulsion of the immature fetus
medical management
1. cervical cerclage (shirodkar / Mcdonald)
- done 3 to 4 months (13 to 14 weeks)
- surgical procedure to prevent incompetent cervix to happen again
- if CS, cervical cerclage remove after CS, CS done 14 days before
EDC to avoid dilatation & contractions
- sutures serve ti strengthen the cervix & prevent it from dilating
- purse string sutures are placed in the cervix by vaginal route
1. avoid coitus or orgasm
2. provide routine post-op
3. maintain bed rest for 24 hours (modified trendelenburg position)
4. observe for ruptured membranes and bleeding
5. monitor FHR and Doppler ultrasound
6. avoid strenuous play activity
1. states intention of seeking immediate medical care if labor begins
2. continues pregnancy to term
1.body image disturbance RL to feelings of failure and feelings of guilt
2. anticipatory grieving RL to loss of expected baby
3. knowledge deficit RL to cerclage procedure and effect on pregnancy
4. pain RL to early dilation of the cervix
5. situational low self-esteem RL to inability to complete pregnancy

5. Hyperemesis gravidarum

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- severe nausea and vomiting, leading to electrolyte metabolic and nutrition imbalances in the
absence of other medical problems
- sometimes called “pernicious vomiting” during 14 to 16 weeks gestation
- peak: 10th week of gestation

1. signs and symptoms occur during the 1st 16 wks of pregnancy and are
2. continued vomiting results to dehydration
3. secretion of HCG, decrease in free gastric HCl., decreased
gastrointestinal motility
4. increased incidence in H-mole and multifetal pregnancy
5. hospitalization may be required for severe symptoms
1. unremitting / intractable nausea and vomiting
2. hiccups
3. abdominal pain
4. marked weight loss
5. dehydration – thrist, tachycardia, skin turgor
6. increased respiratory rate
7. elelvated blood urea nitrogen
1. altered nutrition, less than body requirements RL to retain oral feedings
2. fluid volume deficit RL to dehydration
3. Ineffective individual coping RL to symptoms, insecurity in role
4. personal identity disturbance RL to symptoms or perception of self as
inadequate in role, sick, socially unrepresentable
Goal: physiological stability
a. rest GI tract (keep NPO), maintain IVF, parenteral nutrition
b. progress diet, as ordered, present small feedings attractively
c. weigh daily, assess hydration, note weight gain
Goal:minimize environmental stimuli
a. limit visitors and phone calls
b. bed rest with BRP
Goal: emotional support
a. establish accepting, supportive environment
b. enouragce verbalization of anxiety, fears, concerns
c. support positive self-image
a. woman s/s subsdies, she takes oral nourishment & gains weight
b. woman’s pregnancy continued to term /o recurrence of hyperemesis

Morning sickness HG
Onset occurs in 1st trimester & resolves in 2nd onset in 1st trimester and
continues throughout
Weight is maintained weight loss
Serum electrolytes remain normal serum electrolytes are
Ketosis doesn’t develop ketosis occurs or maybe
Skin turgor remains hydrated skin turgor is dehydrated
Serum thyroid level normal serum thyroid levels are
Skin color – normal jaundice may occur

6. Placenta Previa

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- abnormal or low implantation of the placenta near or over the internal OS

- is a condition in which the placenta attached itself to the uterine wall in the lower
portion of the uterus and covers all or part of the cervix
- condition in pregnancy in which the placenta lies below the babe in the uterus and may
completely block the opening of the uterus (cervix)
* 9-10% are associated with
Placenta Accreta – an abnormal attachment of the placenta to the uterine wall,
that prevents the placenta from separating from the wall of the uterus at
the time of delivery
If placenta accreta is present = profuse bleeding
= requires blood transfusion
Type of placenta previa
1. Low lying or Type I
– when the placenta is implanted in the lower uterine
- as early as 3 months
2. Marginal or Type II
– when the placenta is at the margin of the internal OS
3. Partial or Type III
– when the placenta partially covers the internal OS
4. Complete or Type IV
– when the internal cervical OS is completely covered by the placenta

Type 1-3 = trial NSD

Type IV = CS

Predisposing factors
1. multi parity (5% in grand multiparous Px)
2. advanced maternal age (35 yrs above – high risk)
3. multiple gestations – twins, triplets, etc
4. previous CS
5. uterine incisions – prior uterine insult or injury
6. prior placenta previa (4-8%)
7. prior induced abortion
8. smoking
Assessment S/S
a. bright red, painless vaginal bleeding
b. soft, nontender uterus
c. FHR stable and within limits – normal FHT
d. hypotension
e. tachycardia
f. absence of contractions
Diagnosed by:
1. ultrasound
2. double set-up examination – vaginal exam in operating room only,
in preparation for CS
3. CBC
4. Speculum exam or careful spec exam – to determine if bleeding is
from mother or from fetus
Nursing care plan
1. take and record vital signs, assess bleeding and maintain pad count
2. observe for shock
3. monitor FHR
4. enforce strict bed rest
5. explain condition and management options
6. instruct client to avoid intercourse until after birth
Medical management
1. ultrasound is used to locate the placental site

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2. amniocentesis – to determine if the featl lung is mature enough for

3. Kleihauer-Betke Test – test strip to detect if bleeding is from mother
or fetus
4. vaginal birth possible – if bleeding is minimal
5. cesarean birth
Magnesium Sulfate – used to stop uterine contractions
Bethamethosome – to increase fetal lung maturity if pre-term labor
can’t be halted
Note: After delivery with placenta previa, patient is at risk for 2
1. post-partal hemorrhage
2. endometritis

7. Abruptio Placenta
- premature separation of normally implanted placenta from the wall of the uterus
- occurs as late as during the 1st or 2nd stage of labor

1. partial abruption placentae – small part of the placenta
2. marginal – occurs at the edges, external bleeding
3. compete – total placenta separates
1. Cause is unknown
2. risk factors
a. uterine anomalies
b. multiparity (before birth or second twin)
c. PIH (preeclampsia / eclampsia)
d. previous CS delivery
e. renal or intravascular disease (chronic renal hypertension)
f. trauma to abdomen
g. previous 3rd trimester bleeding
h. abnormally large placenta
i. traction on umbilical cord
j. cigar smoking (cocaine addiction)

Signs and Symptoms

- sudden, localized, sharp, stabbing uterine pain
- knife-like abdominal pain
- concealed or external dark red vaginal bleeding
- convelaire uterus
- uterine outline possibly enlarged
- FHR present or absent

Severe Abruptio Placentae – observe for complications

- hemorrhage or shock
- renal failure
- dissiminated intravascular coagulation (DIC)
- maternal or fetal death

Nursing interventions for stabilization

- place on strict bed rest (LLP)
- O2 therapy by nasal cannula 4.6L
- fetal monitoring
IV line – using an 1.8 guage needle
- accurately chart fluid intake (IV) and output

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- strict NPO
- observe vaginal bleeding for 30 mins
Planning and implementation
1. continuously evaluate maternal and fetal physiological status:
vital signs
electronic fetal and maternal monitoring tracings
signs of shock
decreased urine output
2. never perform a vaginal or rectal exam or take any action that would stimulate
urine activity
3. Assess the need for immediate delivery
- CS
- vaginal delivery (NSD)
* CS - necessary for live, distressed or uncontrolled bleeding, because the
mother can die within 30 mins from severe hemorrhaging
* NSD – should be attempted when the fetus is dead, maternal bleeding is mild,
mother is in stable condition – induction of artificial labor

8. Pregnancy-induced Hypertention
- a hypertensive disorder of pregnancy, developing after 20 weeks of gestation and
characterized by edema, hypertension and proteinuria
- associated with poor calcium in the urine and magnesium sulfate
- vasospasm occur during pregnancy

1. cause is unknown
2. possible contributing factors
- poor renal care, particularly inadequate nutrition
- primigravid status
- multiple pregnancies
- preexisting maternal diabetes mellitus or hypertension
- age younger than 18 or older than 35 yrs
- Hydatidiform mole
- low socioeconomic form
Mild preeclampsia
- hypertension – systolic increase of 30 mmHG or more over baseline;
diastolic rise of 15 mmHG or more over baseline (ex. 140/90)
- proteinuria – 1 g/d
edema – digital and periorbital; weight gain over .45 kg (1 lb) per week
Severe preeclampsia – increasing hypertension – systolic at or above 160
mmHG or more than 50 mmHG over baseline; diastolic 110 mmHG or
- rapid rise in BP
- rapid weight gain
- generalized edema
- increased proteinuria
- epigastric pain
- severe headache
- visual disturbances
- oliguria
- irritability
- severe nausea and vomiting

- tonic and clonic convulsions (grand malseizures), coma
- renal shutdown – oliguria, anuria

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- accompanied by s/s of preeclampsia

WARNINGS signs of impending seizures

1. frontal headache
2. epigastric pain
3. sharp cry
4. eyes fixed, unresponsive
5. facial twitching
* magnesium sulfate: drug of choice to halt contractions, CNS
depressant action that slows & helps uterine

Goal: seizure care of eclamptic patient

1. maintain patent airway
2. administer medications / fluid as ordered
3. assess uterine activity for labor or AP
4. check perineum for impending labor
5. check HR
6. observe, report and record
- onset and progression of convulsion
- if followed by coma and/or incontinence

Emergency: magnesium sulfate toxicity

Assess for S/S
- respiration less than 12/min
- urinary output less than 30 ml/hr
- toxic serum levels more than 9.6 mg/dl
fetal distress: drop in FHR, no fetal movements
- significant drop in maternal pulse or BP
- significant drop in maternal pulse or BP
Collaborative management
1 STAT: DC MgSO4; open maintenance IV line
2. call for assistance STAT; notify attending physican
3. antidote for Mg toxicity = administer calcium gluconate or calcium
chloride as ordered
4. monitor frequently: VS, MgSO4, serum levels

NCP : PIH (hospitalized)

1. VS every 2-4 hrs – note, record, and report persistent HPN
2. monitor FHR
3. I&O, to identiy diuresis
4. urinalysis (clean catch)
5. observe for signs of labor (AP
6. daily weight, amount and distribution of edema (pitting, pedal, digital,
periorbital) to identify signs of mobilization of fluid, diuresis
1. increased protein intake – to increase blood osmolority
2. do not eliminate sodium, but avoid food increase in salt (potato
chips, pickles)
3. avoid alcohol & smoking
4. fluid intake: 8-10 glasses/day
5. food with roughage – to stimulate peristalsis
1. anxiety RL to cause of pregnancy and possible death of the fetus
2. fluid volume deficit RL to fluid shift from intravascular to extravascular
space secondary to vasospasm
3. risk for injury to mother RL sedation and seizures
4. risk for trauma to mother RL to magnesium toxicity

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- begins from the start of labor to 1 to 4 hours after delivery

Induction of labor
- is the deliberate initiation of labor before spontaneous contractions begin
- means that the labor is artificially started may be either mechanical, physiologic or chemical
* mechanical = amniotomy
* physiologic = ambulation
* chemical = methergine
Primary reasons for inducing labor
1. overdue (at least 1 to 2 weeks)
2. toxemia (elevated blood pressure)
3. PROM (prolonged rupture of membrane)
4. chorioamnionitis (infection of membrane)
5. oligohydramnios
6. macrosomia
7. prior poor obstetrical Hx (prior stillborn)
8. intrauterine fetal death
Reasons for not inducing labor
1. placenta previa (after birth in front of the baby's head)
2. prior classical C-section (incission is up and down on the uterus
3. breech baby or other abnormal fetal positions
4. fetal distress
5. active herpes infection (can affect fetus - opthalmia neonaturum)
Before inducing labor, these conditions must be considered:
1. abscence of CPP, malpresentation or malposition
2. cervix is ripe, or ready for birth
3. engaged vertex of single gestation
4. the fetus is estimated to be matured by date
Methods of inducing labor
1. induction by AROM (artificial rupture of membrane - amniotomy)
- may be adequate to stimulate contractions and increased effectiveness of
- is initiated when the cervix is soft, partially effaced, and slightly dilated,
preferably when the fetal presenting part is engaged
- maybe done after oxytocin administration establishes effective contraction
Assessment during induction of labor
1. observe fluid - note color,amount
2. monitor FHR, assess for fetal distress
3. observe for signs of prolapsed cord
4. assess fetal activity
- excessive activity may indicate distress
- absence of activity may indicate distress or demise

Induction of labor by prostaglandin (gel/suppositories)

- this is the most commonly used method of speeding cervical ripening
- have a unique ability to soften and dilate the cervix w/o painful contractions

- the more favorable the cervix, the less like the induction is needed
- sometimes this is all that is needed
- takes longer to get into active labor
- mother becomes nauseated or has headaches
- trigger labor or lead to over-stimulation by the uterus
- hyperstimulation results in C-section

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Induction of labor by oxytocin

- initiates contractions in a uterus at pregnancy term to cause contractions
- oxytocin is administered intravenously, or by dilute administration of an intravenous form
- amount is increased every 15-30 mins until contraction pattern is achieved

- easier to control the AROM
- faster effect
- can cause fetal distress
- may or may not cause contractions - absent; last too long

Cesarean delivery
- surgical / operative by which infant or newborn is delivered through incisions in abdominal
and uterine walls to give brith

Indications of CS
1. previous CS
2. dystocia
3. hemorrage
4. fetal distress
5. preeclampsia
6. prolonged rupture of membrane
7. prolapsed cord
8. intrapartum infection
9. elederly primigravidas
10. Rh incompatibility
11. previous surgery
12. placenta previa / abruptio placenta
13. macrosomia
14. fetal maternal death
Types of cesarean incisions
1. classic cesarean incision
- a vertical midline skin incision is made in the skin and the body of the
- indicated in emergency situations
- necessary for anterior placenta previa and transverse lie
- permitting easier access to the fetus
- blood is increased
2. low segment incision
- this is the most common type of incision
- the incision is low (bikini or Pfannestiel's incision)
- the uterine incision is horizontal in the lower urterine segment
- blood loss is minimal / less adhesion formed
3. porro's hysterotomy followed by hysterectormy
- hemorrage from uterine atony
- placenta previa, accreta
- large uterine mayomas
- ruptured uterus
- cancer of uterus or ovary
1. self-esteem disturbance RL to failure to give birth vaginally
2. anxiety and fear RL to surgical operation
3. ineffective individual coping
4. fluid volume deficit RL to blood loss
5. pain RL to abdominal surgery
6. constipation RL to decreased bowel activity
1. pre-operative

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a. monitor FHR continually

b. notify neonatology and NICU of schedule surgical birth
c. describe, discuss anticipated anesthesia
d. explain procedure for preoperative antacids
e. prepare for CS birth

Prolapsed umbilical cord

(33 - 35 cm normal length of cord)
- occurs when the baby's umbilical cord falls into the birth canal ahead of the baby's head or
other parts of the baby's body

- prematurity (SGA) - allows space for cord descent
- unengaged cephalic presentation w/ ruptured membranes
- shoulder and footling presentation
- polyhydramnios
- placenta previa
- signs of fetal distress may develop as the cord is compressed
- the prolapse of the cord may be visible or palpable
Goal: reduce pressure on cord
- position = place client in knee-chest position; lateral modified Sim's
with hips elevated; modified Trendelenburg position
- with gloved hand, suport fetal presenting part off cord
Goal: increase fetal-maternal oxygenation
- O2 per mask (8-10 L/min)
Goal: protect exposed cord
- cord with warm sterile saline dressing
Goal: expedite termination of threat to infant
- prepare for immediate vaginal / cesarean birth
*Cervix is fully dilated @ the time of prolapsed cord - the
physician may choose to deliver the infant quickly with possibly
forceps delivery to prevent period of anoxia.

*Incomplete dilatation - the birth method of choice is upward

pressure on the presenting part to keep pressure off the cord - CS

Pre-term labor
(20-37 weeks)
- labor that begins after 20 weeks gestation and before begining of week 38

- preeclampsia
- hydramnios
- placenta previa
- abruptio placenta
- incompetent cervix
- trauma
- multiple gestation
- intrauterine infection
- uterine structural anomalies
- congenital adrenal hyperplacia
- fetal death
Manifestations of preterm labor
- rhythmic uterine contyractions
- cervical effacement and dilatation
- possible rupture of membranes

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- expulsion of the cervical mucus plug

- bloody show

A. primary - close obstetric observation; education is warning signs and symptoms
of preterm labor
1. dull lower backache that radiates like a wave to the front of the abdomen
2. contractions every 10 minutes for 2 hours even after position changes
3. low back pain and light bloody discharge (bloody show)
4. pelvic pressure extending to the back and thighs
B. secondary - prompt, effective treatment of associated disorders
C. tertiary - suppression of preterm labor
1. bedrest
2. position: side-lying - to promote placental perfusion
3. hydration - IV fluids
4. pharmacologic - like Beta-andrenergic agents - to reduce sensitivity of
uterine myometrium to oxytocic and prostaglandin stimulation;
increase blood flow to teh uterus
5. may be maintained at home with adequate follow up and health teaching

* magnesium sulfate - is a CNS depressant that acts to block neuromuscular

transmissions to halt convulsions. IT can also be used to halt premature
* terbutaline - to enhance lungs (immature lungs); to prevent respiratory tract
infection; to prevent obstruction airway of the lungs
* ritodrine - to prevent or halt premature labor

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