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Jay Lapaz Andres, RN, BSN Nurse Educator/National Reviewer UDMC-SACI Manila, Philippines

Anatomy and Physiology Female External Structures (Vulva) Mons veneris a pad of adipose tissue located over the symphysis pubis; covered by hairs; protects the junction of the pubic bone from trauma. Labia minora hairless folds of connective tissue located posterior to the mons veneris; the folds are pink in color. Labia majora two folds of adipose tissue positioned lateral to the labia minora; covered by pubic hair and protects the external genitalia, distal urethra and vagina. Other external organs: Vestibule the flattened, smooth surface inside the labia minora where the urethral meatus and vagina both arise. Clitoris a small (1 to 2cm) rounded organ of erectile tissue at the forward junction of the labia minora. It is the center of sexual arousal and orgasm in female. Skenes glands (paraurethral glands) located just lateral to the urinary meatus; with alkaline secretions that lubricate the external genitalia during coitus. Bartholins glands (vulvo-vaginal glands) located just lateral to the vaginal opening; with alkaline secretions as lubricant during coitus. Fourchette ridge of tissue formed by the posterior joining of the two labia minora and the labia majora; the structure that is cut during episiotomy. Hymen a tough but elastic semi-circle of tissue that covers the vaginal opening ; torn during the time of first sexual intercourse. Female Internal Structures Ovaries almond-shaped gonads that produce, mature, and discharge ova; produce estrogen and progesterone and regulate menstrual cycles. The cortex is filled with immature (primordial) follicles that will form the graafian follicles. The central medulla contains the nerves, blood vessels, and lymphatic tissue. Fallopian tubes approximately 10 cm in length; convey the ovum from the ovaries to the uterus and provides a place for fertilization. The interstitial portion is the most proximal division. The isthmus is the next distal portion about 2 cm in length and is cut and sealed in a tubal ligation. The ampulla is the third and longest portion of the tube about 5 cm where fertilization occurs. The infundibular portion is the most distal segment of the tube and is funnel-shaped. Uterus a hollow, muscular pear-shaped organ where implantation and nourishment during fetal growth occurs. It weighs approximately 60 g in a non-pregnant state. The body or corpus is the uppermost part that forms the bulk of the uterus and expands to contain the growing fetus. The fundus is the portion that can be palpated abdominally. The isthmus is a short segment between the body and the cervix; most commonly cut when a fetus is born by a cesarean birth. The cervix is the lowest portion of the uterus.

Uterine layers: Endometrium inner layer of mucous membrane. The basal layer is the layer closest to the uterine wall. The inner second glandular layer is the layer that is shed as the menstrual flow. Myometrium middle layer of muscle fibers that offer extreme strength to the organ. Perimetrium outermost layer of the uterus that offers added strength and support. Uterine supports: Posterior ligament is a fold of peritoneum behind the uterus that forms a pouch (Douglas cul-desac) between the uterus and the rectum. Broad ligaments are two folds of peritoneum that covers the uterus front and back and extend to the pelvic sides. Round ligaments are two fibrous muscular cords that pass from the body of the uterus through the broad ligaments and act as stays to steady the uterus. Uterine Deviations: Anteversion the fundus is tipped forward. Retroversion the fundus is tipped back. Anteflexion the body is bent sharply forward. Retroflexion the body is bent sharply back. Vagina acts as the organ of intercourse and conveys sperm to the cervix. It expands to serve as the birth canal during childbirth. Doderleins bacillus is the lactose-fermenting bacteria that break down the glycogen content of the vaginal mucous secretions to form lactic acid. Breasts mammary glands. Milk glands of the breasts are divided approximately into 20 lobes. Acinar cells produce milk in each lobe. The nipple has approximately 20 openings through which milk is secreted. The ampulla just posterior to the nipple serves as milk reservoir before breastfeeding. Oxytocin acts to constrict milk glands cell and pushes milk forward.

Pelvis a bony ring formed by four united bones: two innominate flaring hip bones that form the anterior and lateral portion ; the coccyx and sacrum which form the posterior aspect.

Three parts of the innominate bone: Ilium upper and lateral portion. Ischium inferior portion. Ischial tuberosities are two projections at the lowest portion of the ischium and is the portion on which a person sits. Pubis the anterior portion. The symphysis pubis is the junction of the innominate bones at the front of the pelvis. Sacrum the upper posterior portion of the pelvic ring. Coccyx below the sacrum, composed of five very small bones fused together. False pelvis the superior half; supports the uterus during the late months of pregnancy and aids in directing the fetus into the true pelvis for birth. Linea terminalis an imaginary line that divides the false pelvis from the true pelvis. It is drawn from the sacral prominence to the superior aspect of the symphysis pubis. True pelvis the inferior half.

Inlet the entrance to the true pelvis at the level of linea terminalis. The passageway appears heartshaped because of the sacral prominence. The transverse diameter is wider than the antero-posterior diameter. Outlet the inferior portion bounded in the back by the coccyx. The antero-posterior is the greatest diameter. Pelvic cavity is a curve passage between the inlet and the outlet. It slows and controls the speed of birth and therefore reduces sudden pressure changes in the fetal head. Ischial spines marks the midpoint of the pelvis. This marker is used to assess the level to which the fetus has descended into the birth canal during labor. Male External Stuctures Penis composed of corpus cavernosa; corpus spongiosum (cylinder). - outlet for both urinary and reproductive tracts; penile erection is stimulated by parasympathetic nerve innervation. Scrotum - rugated muscular pouch that contains the testes and epididymis; helps regulate the temperature of sperm. Testes - two ovoid glands 2 to 3 cm wide that lies in the scrotum. The seminiferous tubules produce spermatozoa; the Leydigs cells produce testosterone. Sperm production Hypothalamus releases GnRH APG releases FSH (releases androgen-binding protein) and LH (releases testosterone) ABP + testosterone = spermatogenesis. The minimum sperm count considered normal is 20 million spermatozoa per mL of seminal fluid, or 50 million per ejaculation. The average normal sperm count is 50 to 200 million per mL. An average ejaculation should produce 2.5 to 5.0 mL of semen Semen is derived from: Prostate gland 60% Seminal vesicles 30% Epididymis 5% Bulbourethral glands / Cowpers glands 5% Male Internal Structures Epididymis tightly coiled tube 20 ft long; conducts sperm from the testis to the vas deferens; storage of sperm. Sperm takes 12 to 20 days to travel the length of epididymis; takes 64 days to reach maturity. Vas deferens carries sperm from the epididymis to the seminal vesicles, ejaculatory ducts; the structure that is severed during vasectomy. Seminal vesicles two convoluted pouches that secrete an alkaline content of a basic sugar, protein and prostaglandins. Ejaculatory ducts pass through the prostate gland and join the seminal vesicles with the urethra. Prostate gland a chestnut-sized gland that secretes a thin alkaline fluid and the majority of the semen contents. Bulbourethral glands secrete an alkaline fluid that helps counteract the acid secretion of the urethra and ensure safe passage of spermatozoa. Urethra a hollow tube leading from the base of the bladder passing through the prostate gland, continues to the outside through the shaft and glans of penis. Approximately 8 inches (18 to 20cm) long.

Homologues Labia majora Scrotum Clitoris Glans penis Ovaries Testes Fallopian tube Vas deferens Estrogen Testosterone

Sexual Response Cycle ( EPOR ) Excitement causes parasympathetic nerve stimulation. In women, clitoris increases in size; mucoid fluid appears on vaginal walls; vagina widens in diameter and increases in length; the nipples become erect. In men, erection occurs; there is scrotal thickening and elevation of the testes. increase in heart, respiratory rate, and blood pressure. Plateau is reached just before orgasm. In women, the clitoris is drawn forward; vagina becomes extremely congested; increased nipple engorgement. In men, full distention of the penis. heart rate increases to 100 to 175 beats per minute and respiratory rate to 40 respirations per minute. Orgasm point at which the body suddenly discharges accumulated sexual tension. Vigorous muscle contraction at the pelvic area expels or dissipates blood and fluid from the area of congestion. This is followed immediately by 3 to 7 propulsive ejaculatory contractions. the shortest stage in the cycle; it is an intense pleasure affecting the whole body. Resolution the internal and external genital organs return to an unaroused state. For the male, there is a refractory period during which further orgasm is impossible. the resolution period generally takes 30 minutes for both. Menstruation Menstrual cycle (female reproductive cycle) episodic uterine bleeding in response to cyclic hormonal changes. It is the process that allows for conception and implantation of a new life. Characteristic Menarche Interval between cycles Duration of menstrual flow Amount of menstrual flow Color of menstrual flow Odor Physiology of Menstruation > 4 body structures involved: 1. Hypothalamus Description Ave.onset 12 or 13 yrs; Ave.range 9 17 yrs Ave.28 days; cycles of 23 to 35 days Ave.2 7 days; ranges 1 9 days Ave.30 to 80 mL / menstrual period Dark red (blood,mucous,endometrial cells) Similar to that of marigolds

2. Pituitary Gland 3. Ovaries 4. Uterus Hypothalamus releases GnRH (Gonadotrophin Releasing Hormone) APG (Anterior Pituitary Gland) produces gonadotropic hormones FSH and LH Ovary produces estrogen and progesterone Uterus (Endometrium proliferates; degenerates). An increase in estrogen and progesterone creates an inhibitory feedback mechanism that halts or represses the hypothalamus to release GnRH for the remainder of the month. FSH is active early in the cycle and is responsible for the maturation of the ovum LH most active at the midpoint of the cycle and is responsible for ovulation (prostaglandin released). 3rd day menstruating; estrogen 13th day - progesterone (BBT drops slightly 0.5 to 1F); estrogen. 14th day - progesterone (thermogenic); remains until 24th day, then progesterone. If fertilization occurs, the corpus luteum will remain up to 16 to 20 weeks of pregnancy. If fertilization does not occur, the corpus luteum will remain only up to 8 to 10 days. Phases of Menstrual Cycle 1st Phase (Proliferative, Estrogenic, Follicular, Postmenstrual) Immediately after a menstrual flow (4 to 5 days) where estrogen level is low, APG produces FSH Ovary produces estrogen. The endometrium begins to proliferate and increases its thickness eightfold. This increase continues for the 1 st half of the menstrual cycle (day 5 to 14). 2nd Phase (Progestational, Luteal, Premenstrual, Secretory) APG produces LH Ovary produces progesterone (corpus luteum). This causes the glands of the endometrium to become corkscrew or twisted in appearance and dilated with quantities of glycogen and mucin, an elementary sugar and protein. The capillaries increase in amount until the lining takes on the appearance of rich, spongy velvet. 3rd Phase (Ischemic) The corpus luteum regresses after 8 to 10 days if theres no fertilization. With decrease progesterone, the endometrium begins to degenerate (day 24 or 25). The capillaries rupture and the endometrium sloughs off. Menses (Final Phase) The end of an arbitrarily defined menstrual cycle. Because it is the only external marker of the cycle, the first day of menstrual flow is used to mark the beginning day of a new menstrual cycle. The iron loss in a menstrual flow is 11mg. Teaching About Menstrual Health Area of Concern Exercise Sexual relations ADL

Teaching Points Moderate exercise to increase abdominal tone. Not contraindicated during menses; male should wear condom; orgasm may increase menstrual flow. Nothing is contraindicated.

Pain relief Rest Nutrition Menstrual disorders: Dysmenorrhea painful menstruation. Menorrhagia abnormally heavy menstrual flow. Metrorrhagia bleeding between menstrual periods.

Mild analgesic; Ibuprofen (Motrin) is specific. More rest is helpful if with dysmenorrhea. Iron supplementation.

Menopause the cessation of menstrual cycles; between 40 and 55 years. Both the age of menarche and the age of menopause tend to be familial. The earlier the age of menarche, the earlier menopause tends to occur.

Estimating Date of Birth Nageles Rule * Determine the first day of LMP, subtract 3 calendar months, add 7 days and 1 year. Ex: April 8, 2007 is the 1st day of the LMP 4 08 2007 -3 +7 ---------------------------------EDB 1 15 2008 (January 15, 2008) Estimating the AOG McDonalds Rule measures the fundal height in cm * the distance from the notch of the symphysis pubis to over the top of the uterine fundus in centimeters - becomes inaccurate during the 3rd trimester because the fetus is growing more in weight than in height during this time. * Typical milestone - over the symphysis pubis at 12 weeks - at the umbilicus at 20 weeks - at the xiphoid process at 36 weeks

Reproductive Life Planning Contraceptives Natural Family Planning no chemical or foreign material being introduced into the body. Calendar (Rhythm) Method the couple abstains from coitus on the days of a menstrual cycle when the woman is most likely to conceive (3 or 4 days before until 3 or 4 days after ovulation; sperm can survive for 4 days in the female reproductive tract). The woman should keep a diary of 6 menstrual cycles. shortest cycle documented minus 18 = 1st day of fertile period. Longest cycle documented minus 11= last fertile day. Basal Body Temperature Method the woman takes her temperature every morning immediately after waking, before she undertakes any activity. As soon as she notices a slight dip in temperature followed by an

increase, she knows that she has ovulated. She refrains from having sex for the next 3 days (the life of discharged ovum). Cervical Mucus (Billings) Method spinnbarkeit test With ovulation (peak day), cervical mucous becomes copious, thin, watery, and transparent. It feels slippery and stretches at least 1 inch before the strand breaks. All the days the mucous is copious and the 3 days after the peak are fertile days so the couple abstains from sex. Symptothermal Method combines the cervical mucous and BBT. Lactation Amenorrhea Method there is some natural suppression of ovulation as long as a woman is breastfeeding an infant. After 6 months of breastfeeding, the woman should choose another method of contraception. Coitus Interruptus one of the oldest known method. The couple proceeds with coitus until the moment of ejaculation where the man withdraws his penis and the semen is emitted outside the vagina.

Chemical Methods Oral Contraception commonly known as the pill or OCs, are composed of synthetic estrogen combined with a small amount of synthetic progesterone. The estrogen acts to suppress FSH and LH thereby suppressing ovulation. 99.5% effective when used correctly. are packaged 21 or 28 pills to a container. It is recommended that the 1 st pill be taken on a Sunday. Because pills are not effective on the first 7 days, the woman is advised to use a second form of contraception. A menstrual flow begins about 4 days after the woman finishes a cycle of 21 pills. Non-contraceptive benefits include decreased incidences of: dysmenorrhea, due to lack of ovulation iron deficiency anemia, due to reduced amount of menstrual flow Acute pelvic inflammatory disease endometrial and ovarian cancer and ovarian cysts fibrocystic breast disease Side effects nausea, weight gain, headache, breast tenderness, breakthrough bleeding, monilial vaginal infections, mild hypertension, depression. Absolute and possible contraindications to oral contraceptive use: Absolute Possible Breastfeeding Diabetes Mellitus Family hx of CVA and CAD High blood pressure Hx of thromboembolic disease Obesity Hx of liver disease Smoking Thrombophlebitis Migraine or other vascular-type headaches

Increased estrogen in the body has an effect of increased tendency towards clotting, particularly to women with history of thromboembolic disease, CVA. Taking pills with high estrogen content decrease the womans milk supply, resulting to lower weight gains of breast-fed infants. Women may take progesterone-only pills (mini-pills) during breastfeeding. High levels of estrogen or progesterone might be teratogenic to a growing fetus. After a woman stops taking an OC, she may not be able to become pregnant for 1 to 2 months, and possibly 6 to 8 months because the pituitary gland requires a recovery period. Women older than 40 years who smoke are not candidates for OCs because of the danger of cardiovascular complications. Subcutaneous Implants consists of 6 non-biodegradable Silastic implants that are filled with progesterone and embedded just under the skin on the inside of the upper arm. the implant slowly release the hormone over the next 5 years, suppressing ovulation, stimulating thick cervical mucous, and changing the endometrium so implantation is difficult. the rapid return to fertility (about 3 months after removal) is an advantage. a disadvantage is the cost, $500 on average. Side effects are weight gain, irregular menstrual cycle, hair loss, depression. Intramuscular Injections single injection of medroxyprogesterone acetate (DMPA or Depo-Provera) given every 12 weeks. The effectiveness rate is nearly 100%. Depo-Provera can be used during breastfeeding. The woman must have the injection every 12 weeks for the method to remain reliable. The return to fertility is often delayed by about 6 to 12 months. Woman should be advised to include an adequate amount of calcium in their diet because of the slight increase in the risk for osteoporosis. Potential side effects are similar to subcutaneous implants. Intrauterine Devices small plastic object inserted into the uterus through the vagina that interferes with fertilization. Copper T380 (ParaGard), a T-shaped plastic device wound with copper, affects sperm mobility. This decreases the possibility of sperm successfully traversing the uterine space and reaching the ovum. It is effective for 8 years. Side effects: higher than usual risk for PID (fever, lower abdominal tenderness, pain on intercourse); also a higher risk of ectopic (tubal) pregnancy. should take active steps to avoid toxic shock syndrome (staphylococcal infection). not recommended for women who have never been pregnant, who have multiple sexual partners, or who have a history of PID. Barrier Methods Spermicidal Products these agents cause the death of spermatozoa before they can enter the cervix. They change the vaginal pH to a strong acid level, a condition not conducive to sperm survival.

include gels, creams, films, foams, and suppositories. Gels or creams should be inserted into the vagina no more than 1 hour before coitus for the most effective results. should not douche for 6 hours after coitus. contraindicated in women with acute cervicitis because they might further irritate the cervix. Advantages: may be purchased without a prescription. uses the preferred ingredient Nonoxynol-9, may help prevent STDs. maybe used in conjunction with another contraceptive to increase effectiveness. Diaphragms a circular rubber disk that is placed over the cervix prior to intercourse. Side effects and contraindications: may experience a higher number of UTIs because of pressure on the urethra. should not be used in the presence of acute cervicitis. contraindicated to those with history of toxic shock syndrome (elevated temperature, diarrhea, vomiting, muscle aches); allergy to rubber or spermicides; history of recurrent UTIs. Guidelines: must be inserted before coitus and should be left in place for 6 hours afterward. may be left in place for as long as 24 hours. If left longer than this, may cause cervical inflammation and urethral irritation. Use mild soap and water to wash the diaphragm; will last for 2 to 3 years. Cervical Caps made of soft rubber, shaped like a thimble and fits snugly over the uterine cervix. tends to dislodge more readily than diaphragms during coitus. can remain in place longer than diaphragms because they do not put pressure on the vaginal walls or urethra, but not to exceed 24 hours. Contraindications: an abnormally short or long cervix. a previous abnormal Pap smear. a history of toxic shock syndrome an allergy to latex or spermicide a history of PID, cervical cancer Male Condoms latex rubber or synthetic sheath that is placed over the erect penis before coitus. one of the few male-responsibility birth control measures available and no prescription is needed. prevents the spread of STDs Guidelines: condoms should never be reused. should be positioned loose enough at the penis tip to collect the ejaculate. the penis must be withdrawn after ejaculation before it begins to become flaccid. Female Condoms latex sheaths made of polyurethane and lubricated with nonoxynol-9.

the closed end covers the cervix and the open end rests against the vaginal opening. are also intended for one-time use and offers protection against both conception and STDs. Surgical Methods Vasectomy the vas deferens is cut, tied, cauterized or plugged thereby blocking the passage of spermatozoa. The procedure is 99.9% effective. can resume intercourse within one week but needs additional birth control methods. Spermatozoa that were present in the vas deferens at the time of surgery may remain viable for as long as 6 months. needs two negative sperm reports, usually 10 to 20 ejaculations to ensure that all sperm in the vas deferens have been eliminated. Tubal Ligation the fallopian tubes are occluded by cautery, crushing, clamping, or blocking the tubes and thereby preventing the passage of sperm and ova. It has 99.9% effectiveness rate. may return to having coitus as soon as 2 to 3 days after the procedure, provides immediate contraception. Sperm count - is the number of sperm in a single ejaculation or mL of semen. - the minimum sperm count considered normal is 20 million per mL of semen, or 50 million per ejaculation (the average normal sperm count is 50 to 200 million per mL) - average ejaculation should produce 2.5 to 5.0 mL - at least 60% of sperm should be motile, and 60% should be normal in shape and form. Contraception METHOD Hormonal Contraceptives Combination of estrogen and progesterone

ACTION / EFFECTIVENESS Suppresses ovulation by suppressing production of FSH and LH Most efficient form of contraception (99.5%) if used consistently


DISADVANTAGES / SIDE EFFECTS Absolute and possible contraindications Some decrease in glucose tolerance No protection against STDs Risks: uterine perforation, infection, may be followed by PID Side effects: heavy flow, spotting, cramping Contraindications: history of PID; abnormal uterine cavity No protection against

Convenient; easy to take Withdrawal bleeding cycles are predictable Many non-contraceptive health benefits

Intrauterine Devices (IUDs)

Prevents fertilization Damages sperm in transit to fallopian tube Alters cervical mucus and endometrial maturation Effectiveness rate: 90-

Can be used by women who cannot use hormonal contraception No disruption of ovulation pattern Can be used effectively for 10 yrs (Copper)

99% Barriers Diaphragm A barrier that prevents sperm from entering the cervix Effectiveness:83-90% Does not interrupt the sex act Insert up to 6h before coitus and leave in place for 6h after coitus but no longer than 24h Worn for 8h but not longer than 48h

STDs Requires careful cleansing with warm water and mild soap Must be refitted by health care provider after weight gain or loss of 20 lb or more, or every 2 yrs Need a Pap smear every year If left in place for over 48h, risk of TSS Must be checked each year No protection against STDs Must be properly applied and removed Check expiration date Aids lubrication to vagina Requires no prescription Messy Suppositories take 5 mins to dissolve Allergy to preparations

Cervical cap

Physical barrier to sperm Spermicide inside cap adds a chemical barrier Effectiveness similar to diaphragm


Barrier preventing sperm from entering vagina Effectiveness rate: 64 98% Chemical barrier and action to kill sperm Effectiveness rate: 70 to 98% when used with diaphragm or condom Requires sexual abstinence during womans fertile period (4d before, 4d after ovulation) Effectiveness rate: 80%

Provides protection from spread of STDs


Fertility Awareness

Physically safe no drugs are being used

Effectiveness depends on motivation and diligence

Meets requirements of most religions

Sterilization Vasectomy

Vas deferens is occluded to prevent passage of sperm

Does not affect endocrine function, production of testosterone

Sterility is not immediate. Sperm are cleared from vas deferens after 20 ejaculations.

Does not alter volume of ejaculate Tubal Ligation Fallopian tubes are ligated to prevent passage of ova Greater than 99.5% effective Possible complications of infection, hemorrhage after surgery

Pregnancy Hormones of Pregnancy: Primary Effects ESTROGEN Uterine development Breast development Genital enlargement Softens connective tissue Antagonist to insulin Primary Effects PROGESTERONE Development of decidua Reduces uterine excitability Development of mammary glands Antagonist to insulin Decreases gastric motility & relaxes sphincters Increase BBT by 0.5C HUMAN CHORIONIC GONADOTROPIN Maintains corpus luteum during early pregnancy Diagnostic value Clinical Implications Probable sign of pregnancy Probable sign; increased tingling; tenderness Vaginal growth facilitates vaginal birth Results in backache and leg ache; relaxes joints to increase size of birth canal and rib cage Makes glucose available to the fetus Clinical Implications High levels result in tiredness, listlessness, and sleepiness Protection against abortion / early birth Prepares breast for lactation Diabetogenic Favors heartburn and constipation Discomfort from hot flashes and perspiration

Placenta must take over after a few weeks Basis for pregnancy test Hydatidiform mole Decreased level with threatened miscarriage Increased level with multiple pregnancy

HUMAN PLACENTAL LACTOGEN Antagonizes insulin PROLACTIN Suppressed by estrogen and progesterone Increased level after placenta is delivered FSH

Diabetogenic; complicates management of existing diabetes No milk produced before birth Milk production 2-3 days after birth

Production suppressed during pregnancy OXYTOCIN Uterine contraction

No ovulation during pregnancy Labor induction or augmentation; treatment for postpartum uterine atony

Common Discomforts During Pregnancy DISCOMFORT CAUSE Morning sickness Hormonal, psychological, empty stomach Fatigue (sleep hunger) Urinary frequency Hot flashes Heartburn Flatulence Shortness of breath Backache Constipation Ankle edema Varicose veins Prenatal Terms related to pregnancy status: 1. Gravida refers to present pregnancy; a pregnant woman. Nulligravida woman who has never been pregnant. Primigravida woman with a first pregnancy. Multigravida woman with a second or later pregnancy. Hormonal Enlarging uterus presses on bladder Increased metabolism Enlarging uterus and hormones slow digestion Altered digestion from enlarging uterus and hormones Enlarging uterus limits expansion of diaphragm Increased weight of uterus and increased lumbar curvature Decreased motility Normal and non-pitting Pressure of heavy uterus

HEALTH TEACHING Take dry carbohydrate before rising; avoid empty stomach, offending odors, high fat food Adequate rest Limit fluids just before bedtime to ensure rest Alter clothing and environmental temperature Small, frequent meals; limit fatty and fried foods; bend on knees instead of leaning over Avoid gas forming foods Good posture; Fowlers position Low-heeled, wide-base shoes; do pelvic rock Prunes, fruits, vegetables, roughage, fluids Rest legs often during the day with legs and hips raised Elevate legs above heart level

2. Para refers to past pregnancies (not number of babies) that reached viability (>20 weeks; 24 weeks) whether or not born alive. Nullipara woman who has not carried a pregnancy to viability (may have had one or more abortions). Primipara woman who has carried one pregnancy to viability. Multipara woman who had two or more pregnancies that reached viability. Grandmultipara woman who had 6 or more viable pregnancies. To classify pregnancy status: (GTPALM)

G Gravida Para is broken down into: T Full-term infants (infants born at 37 weeks or after) P Preterm infants (infants born before 37 weeks) A Abortion (spontaneous / induced) L Living children M- Multiple pregnancies (considered as one para) Prenatal Clinic Visits - schedule of 1st visit is as soon as the woman missed her menstrual period and pregnancy is suspected. - follow-up visits: once a month up to 1st 32 weeks, twice a month from 32 to 36 weeks, every week from 36 to 40 weeks. Assessment: Breasts - breast areola darkens - Montgomery tubercles become prominent - breast size increases - breast tone firms - secondary areola develops surrounding the natural one - blue streaking of veins become prominent - colostrum maybe expelled as early as the 16th week of pregnancy Breast Self-examination: - all women should be instructed on monthly breast self-examination. - for the non-pregnant women, the day after the end of each monthly menstrual flow / 7 days after menses is a good marking point.. (breast tissue is normally not swollen and examination is not uncomfortable) - when pregnant, the woman should specify a certain day each month. Self-examination - is initiated / taught at the time of first pelvic examination; done monthly at the end of menses Clinical examination - every 3 years, ages 20 to 39; annually after age 40 Papanicolaou smear - initially, 3 years after becoming sexually active but no later than age 21 - every 2 to 3 years after age 30 and after three normal test results in a row Mammography - every 1 to 2 years between ages 40 and 49 and annually thereafter Fundal Height - about 12 to 14 weeks, the uterus is palpable over the symphysis pubis as a firm globular sphere. - about 20 to 22 weeks, it reaches the umbilicus. - at 36 weeks, it reaches the xiphoid process. Fetal Heart Sounds - 10 to 12 weeks, FHR can be heard using a Doppler - 18 to 20 weeks, FHR can be heard using a regular stethoscope

Types of Pelves: 1. Gynecoid pelvis normal female pelvis; slightly ovoid or transversely rounded - ideal for childbirth; the inlet is well-rounded forward and backward; the pubic arch is wide. 2. Android pelvis male pelvis; heart-shaped, angulated - the pubic arch forms an acute angle, making the lower dimensions extremely narrow. 3. Anthropoid pelvis ape-like pelvis; oval-shaped - the transverse diameter is narrow and the anteroposterior diameter is larger than normal. 4. Platypelloid flattened pelvis - the inlet is an oval, smoothly-curved but the anteroposterior diameter is shallow. Internal Pelvic Measurements: 1. Diagonal Conjugate - distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis. - it suggest the AP diameter of the pelvic inlet; the most useful measurement for estimation of pelvic size. 2. True Conjugate / Conjugate Vera - measurement between the anterior surface of the sacral prominence and the posterior surface if the inferior margin of the symphysis pubis. - diagonal conjugate minus 1.2 to 2cm (the usual depth of the symphysis pubis) to get the actual diameter of the pelvic inlet. 3. ischial tuberosity diameter - is the distance between transverse diameter of the pelvic outlet. Some Teratogenic Drugs CATEGORY Vit A derivatives Alcohol Analgesics Anticoagulant Antibiotics Caffeine Nicotine Live vaccines

DRUG Isotretinoin (Accutane) Wine, whiskey Acetylsalicylic acid (aspirin); NSAIDs Warfarin (Coumadin) Tetracycline Caffeine Rubella / German measles

DRUG USE Acne Social use Minor pain relief anticoagulation Infection Coffee, softdrinks, chocolate Cigarette smoke Provide immunity

TERATOGENIC EFFECT Craniofacial, cardiac, CNS anomalies Fetal alcohol syndrome Maternal bleeding; PDA Fetal bleeding Teeth and bone deformities Low birth weight Growth retardation Possible infection in fetus

Recommended weight gain during pregnancy - 11.2 to 16 kg (25 to 35 lb) is currently recommended as an average weight gain in pregnancy.

- weight gain in pregnancy occurs from both fetal growth and accumulation of maternal stores. * 0.4 kg (1 lb) per MONTH during the 1st trimester 0.4 kg (I lb) per WEEK during the last two trimesters - pattern of 3-12-12 Normal Prepregnancy BMI Underweight - under 19.8 Normal weight 19.8 to 26.0 Overweight 26.1 to 29.0 Obese - above 29.0 Calorie Needs - the RDA (Recommended daily Dietary Allowances) of calories for women of childbearing age is 2,200. An additional 300 calories is needed during pregnancy, for a total caloric intake of 2,500 calories. (carbohydrate, fat, protein) Protein Needs - the RDA for protein in women is 44 to 46g. During pregnancy, the intake of protein increases to 60g daily. (meat, poultry, fish, eggs, milk) Vitamin and Mineral Needs Folic acid deficiency can lead to megaloblastic anemia (large but ineffective rbc) in the woman as well as fetal neural defects. - is necessary for rbc formation in the mother and preventing neural tube defects in the fetus - folacin-rich foods are green leafy vegetables, oranges, dried beans - folic acid supplement of 0.4 to 1.0 mg - for folic-acid deficiency anemia, the requirement from 400 ug folic acid daily increases to 600 ug / day Iron - the RDA for iron for pregnant women is 30 mg. - dietary supplementation of 15 mg iron per day plus iron-rich foods (organ meats, eggs, green leafy vegetables). - iron absorption increases in an acid environment, with orange juice increases absorption. Iron Deficiency Anemia - the most common anemia of pregnancy. - when the hemoglobin level is below 10 mg/dL and hematocrit under 33%, iron deficiency is suspected. (normal Hgb is 12 to 16 g/dL; normal hct is 37% to 43%) - is characteristically a microcytic (small rbc), hypochromic (less hemoglobin) - is associated with low-birth weight and preterm birth. * Women with iron-deficiency anemia will be prescribed therapeutic levels of medication (120 to 180 mg elemental iron per day) usually prescribed as ferrous sulfate or ferrous gluconate. - advise women to take iron supplements with orange juice or Vit C supplement - diet high in iron and vitamins (green leafy vegetables, meat, legumes, fruit) Common Problems Affecting Nutritional Health 1. Nausea and vomiting (no definite cause but may be related to) - sensitivity to high levels of chorionic gonadotropin hormone produced by the trophoblast

- high estrogen or progesterone levels - lowered maternal blood sugar caused by the needs of developing embryo - lack of pyridoxine (Vit B6) - Diminished gastric motility - notice the sensation as early as the 1st missed menstrual period, and it lasts the 1st 3 months of pregnancy. - usually disappears spontaneously as the woman enters her 4th month of pregnancy. 2. Cravings - an aversion to certain foods during pregnancy are considered a normal part of adaptation to pregnancy. - are more likely the result of a physiologic need for more carbohydrates or particular vitamins and minerals. Pica an abnormal craving for non-food substances. - maybe a craving for clay, dirt, cornstarch, or ice cubes. - because pica is a symptom that often accompanies iron-deficiency anemia, correcting the underlying problem with an iron supplement may correct the pica. 3. Pyrosis (heartburn) - a burning sensation along the esophagus caused by regurgitation of gastric contents into the lower esophagus. - caused by decreased gastric motility that slows gastric emptying. - relieved by eating small meals frequently and by not lying down immediately. The Diagnosis of Pregnancy 1. Presumptive Signs - least indicative of pregnancy; could easily indicate other conditions - highly subjective; experienced by the woman but cannot be documented by the examiner. > Breast changes feeling of tenderness or fullness; enlargement and darkening of areola > Nausea, vomiting especially upon arising > Amenorrhea absence of menstruation (menopause, uterine infection, severe anemia) > Frequent urination sense of having to void frequently > Fatigue general feeling of tiredness > Uterine enlargement can be palpated over symphysis pubis > Quickening fetal movement felt by the woman > Linea nigra line of dark pigment on the abdomen > Melasma dark pigment on the face > Striae gravidarum red streaks on abdomen 2. Probable Signs - can be documented by the examiner; examiners objective findings - not positive or true diagnostic findings > serum laboratory test - detecting the presence of HCG, hormone produced by trophoblast cells; trace amounts of HCG appear in the serum as early as 24 to 48 hours after implantation. > Chadwicks sign color change of the vagina from pink to violet > Goodells sign softening of the cervix

> Hegars sign softening of the lower uterine segment > Sonographic evidence of gestational sac characteristic ring is evident > Ballottement the fetus can be felt to rise against abdominal wall; tossing > Braxton Hicks sign periodic uterine tightening occurs; practice contractions > Fetal outline felt by the examiner palpated through abdomen 3. Positive Signs only three positive signs > demonstration of a fetal heart rate separate from the mothers - 10th to 12th week by the use of Doppler; 18th to 20th week by the use of ordinary stethoscope > fetal movements felt by the examiner > visualization of fetus by ultrasound Milestones of Fetal Growth and Development - both ovulation and gestational age are also measured in lunar months (4-week periods) or in trimesters (3-month periods) - in lunar months, a pregnancy is 10 months (40 weeks or 280 days) 1. 4 weeks > the rudimentary heart > arm and leg buds > rudimentary eyes, ears, nose 2. 8 weeks > organogenesis is complete > heart beats rhythmically > external genitalia present, but sex not distinguishable > facial features discernible > sonogram shows gestational sac 3. 12 weeks > Babinski reflex > Sex is distinguishable > heart beat audible by Doppler > placenta is formed 4. 16 weeks > heart beat audible by ordinary stethoscope > lanugo > sex determined by ultrasound 5. 20 weeks > quickening > vernix caseosa begins to form 6. 24 weeks > production of lung surfactant begins > hearing is demonstrated > pupils reacting to light 7. 28 weeks

> testes begin to descend into scrotal sac > blood vessels of retina are extremely susceptible to damage from high oxygen concentration 8. 32 weeks > subcutaneous fat deposits > moro reflex > birth position (vertex or breech) may be assumed > fingernails grow 9. 36 weeks > lanugo begins to diminish > sole of foot has only one or two crisscross creases 10. 40 weeks > fetus kicks actively > creases on the soles of the feet cover at least two thirds of the surface Complications of Pregnancy First Trimester Bleeding: I. Spontaneous miscarriage Abortion any interruption of pregnancy before the fetus is viable. A non-viable fetus is 20 to 24 weeks gestation or weighing 500g or less. A viable fetus is 24 weeks gestation or weighing more than 400 g. Miscarriage an interruption of pregnancy that occurs spontaneously. 1. Threatened miscarriage - manifested by scant, painless vaginal bleeding, usually bright red; slight cramping but no cervical dilatation. - key intervention is limiting the activity to no strenuous activity for 24 to 48 hours. Complete bed rest is usually not indicated. It may stop the vaginal bleeding but only because blood is pooling vaginally. - spotting usually stops within 24 to 48 hours after the woman reduces her activity. Coitus is restricted for 2 weeks. 2. Imminent (inevitable) miscarriage - if uterine contractions and cervical dilation occur. With cervical dilation, the loss of the products of conception cannot be halted. 3. Complete miscarriage - the entire products of conception (fetus, membranes, placenta) are expelled spontaneously. 4. Incomplete miscarriage - part of the conceptus (usually the fetus) is expelled, but the membranes or placenta is retained in the uterus. 5. Missed miscarriage - the fetus dies in utero but is not expelled. It is usually discovered at a prenatal examination when the fundal height is measured and no increase in size can be demonstrated, or when previously heart fetal heart sounds cannot be heard.

- often, the embryo actually died 4 to 6 weeks before the onset of miscarriage sx. If the pregnancy is not actively terminated, miscarriage usually occurs spontaneously within 2 weeks. * After a miscarriage, because the blood type of the conceptus is unknown, all women with Rh-negative blood should receive Rh(D antigen) immune globulin to prevent the buildup of antibodies in the event the conceptus was Rh-positive. - blood from the placental villi may enter the maternal circulation. If the woman is Rh-negative, enough Rh-positive fetal blood may enter her circulation to cause isoimmunization the production of antibodies against the Rh-positive blood. II. Ectopic pregnancy - implantation occurs outside the uterine cavity. The most common site is the fallopian tube (95%), in which 80% occurs in the ampullar portion. - fertilization occurs as usual in the distal third of the fallopian tube, but because an obstruction is present (salpingitis, tubal scarring), the zygote lodges at the strictured site and implants there instead. - there are no unusual sx, the woman experience the nausea and vomiting of early pregnancy, no menstrual flow occurs, pregnancy test of HCG is positive. - at weeks 6 to 12 of pregnancy, the zygote grows large enough to rupture the slender fallopian tube. The woman experiences sharp, stabbing pain in one of the lower abdominal quadrants at the time of rupture, followed by scant, vaginal spotting. - the therapy for a ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. * As with miscarriage, women with Rh-negative blood should receive Rh immune globulin after an ectopic pregnancy for isoimmunization protection in future childbearing. - if diagnosed earlier, it can be treated with oral administration of Methotrexate. It attacks and destroys fast-growing cells. Because trophoblast and zygote growth is rapid, the drug is drawn to the site of the ectopic pregnancy. Second Trimester Bleeding I. Gestational Trophoblastic Disease (Hydatidiform Mole) - the proliferation and degeneration of the trophobastic villi. As the cells degenerate, they become filled with fluid and appear as fluid-filled, grape-sized vesicles. - tends to occur in women with low protein intake, under age 18 yrs, over age 35 yrs. - because proliferation of the trophoblast cells occurs so rapidly, the uterus tends to expand faster than normally. - no fetal heart sounds are heard because there is no viable fetus. There is marked nausea and vomiting due to high HCG level present. - at week 16, woman will experience vaginal spotting of dark-brown blood or as a profuse fresh flow, accompanied by discharge of the fluid-filled vesicles. - the therapy is suction curettage to evacuate the mole. * Following mole extraction, serum HCG levels are assessed every 2 to 4 weeks for 6 months. The woman should be instructed to use a reliable contraceptive method such as oral contraceptive agent for 6 months. - After 6 months, if HCG levels are still negative, the woman is theoretically free of the risk of developing malignancy. She could then plan a second pregnancy. II. Premature Cervical Dilatation (incompetent cervix) - a cervix that dilates prematurely and therefore cannot hold a fetus until term.

- commonly occurs at 20 weeks of pregnancy; pink-stained vaginal discharge followed by rupture of the membranes, uterine contractions and after a short labor the fetus is born. - associated with increased maternal age, congenital structural defects, and trauma to the cervix. Cervical cerclage a surgical operation to prevent premature cervical dilatation. Purse-string sutures are placed in the cervix at approximately 12 to 14 weeks of pregnancy. a. McDonald procedure nylon sutures are placed horizontally and vertically across the cervix and pulled tight to reduce the cervical canal. b. Shirodkar procedure sterile tape is threaded in a purse-string manner under the submucous layer of the cervix. * The sutures may be removed at 37 to 38 weeks of pregnancy so the fetus may be delivered vaginally. The success rate is 80% to 90%. Third Trimester Bleeding I. Placenta Previa low implantation of the placenta. a. low-lying placenta previa implantation in the lower than in the upper portion of the uterus. b. partial placenta previa implantation that occludes a portion of the cervical os. c. total placenta previa implantation that totally obstructs the cervical os. - associated with increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestation. It is said to occur whenever the placenta is forced to spread to find an adequate exchange surface - the bleeding is abrupt, painless, bright-red. - this is an emergency situation; places the mother at risk for hemorrhage and also compromises the fetal oxygen supply. With loosening of the placenta, preterm labor may begin. * Place the woman immediately on bed rest in a side-lying position. - no vaginal or pelvic examination or enema. II. Abruptio Placenta (Premature Separation of the Placenta) - the placenta has been implanted correctly, but suddenly begins to separate and bleeding results. - the primary cause is unknown, but associated with high parity, short umbilical cord, hypertension, cigarette smoking. - the woman experiences a sharp, stabbing pain high in the uterine fundus as separation occurs. - painful, dark-red heavy bleeding; a hard board-like uterus with concealed hemorrhage; * Keep the woman in lateral position or sims to prevent pressure on vena cava and additional interference with fetal circulation. - no vaginal or pelvic examination or enema. Abruptio Placenta (Degrees of Separation) GRADE 0 1 CRITERIA No sx of separation were apparent from maternal or fetal signs Minimal separation; no fetal distress

2 3

Moderate separation; evidence of fetal distress; uterus is tense and painful on palpation Extreme separation; possible maternal shock and fetal death

III. Preterm Labor - labor that occurs after the 20th week but before the end of 37th week. - occurs for unknown reasons, but associated with dehydration, urinary tract infection, and chorioamnionitis (infection of the fetal membranes and fluid). - common sx: persistent, dull, low backache; vaginal spotting; menstrual-like cramping; increased vaginal discharge; uterine contraction. * The woman is placed on complete bed rest (lateral) to relieve the pressure of the fetus on the cervix. - IV fluid to keep the woman hydrated is initiated because hydration may have an influence on stopping contractions and the release of oxytocin may be minimized; drink enough fluids to remain well-hydrated (8 to 10 glasses) - take an oral tocoytic agent, oral terbutaline (Brethine); Ritodrine Hydrochloride (Yutopar) - avoid activities that could stimulate labor (nipple stimulation). Magnesium sulfate is often the first drug used to halt contractions. It has a CNS depressant action that slows and halts uterine contractions. Dosage: initially 4-6g administered IV as bolus, followed by individually calculated IV infusion rate to maintain designated serum levels. - therapeutic range: 5 to 8 mg / 100 mL - patellar reflex disappears: 8 to 10 mg / 100 mL - respiratory depression occurs: 15 to 20 mg / 100 mL - cardiac conduction defects occur: more than 20 mg / 100 mL Adverse effects: Flushing, thirst; with toxicity, absence of deep tendon reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, and decreased urine output. Nursing implications: - administer continuous infusion piggybacked into main IV line so it can be discontinued immediately. - assess maternal BP and FHR continuously with bolus IV administration. - assess DTR every 1 to 4 hours during continuous infusion use patellar reflex. - monitor intake and output every hour during continuous infusion. Urine output should be 30 mL / hour or greater. - Obtain serum magnesium levels as indicated, every 6 to 8 hours. - Keep calcium gluconate, the antidote for toxicity, readily available at the bedside. Causes of Bleeding During Pregnancy: TIME TYPE ST 1 trimester Threatened miscarriage Imminent (inevitable) CAUSE Unknown; chromosomal; uterine abnormalities ASSESSMENT Painless spotting; slight cramping; cervix closed Spotting; cramping; cervix dilated; + nitrazine test (membranes ruptured)

Complete Incomplete Missed Ectopic pregnancy 2nd trimester Gestational Trophoblastic Disease (H-mole) Implantation of zygote at site other than uterus Abnormal proliferation and degeneration of trophoblastic tissue

3rd trimester

Premature cervical dilatation (incompetent cervix) Placenta previa Abruptio placenta

Cervix begins to dilate and pregnancy is lost at about 20 wks Uterine abnormality Associated with hypertension; short umbilical cord; cigarette smoking Associated with dehydration; UTI; chorioamnionitis

All products of conception expelled Fetus expelled; placenta and membranes retained No apparent loss of pregnancy; fetus dies in utero Sharp, stabbing pain on unilateral lower abdominal quadrant Excessive fundal height for gestation; prolonged nausea and vomiting; absent FHTs; passage of dark blood or grapelike vesicles Painless bleeding leading to expulsion of uterus Painless, bright-red bleeding Sharp,stabbing fundal pain; dark-red bleeding Pink-stained vaginal discharge; uterine contraction

Preterm labor

Pregnancy-induced hypertension (PIH) - condition in which vasospasm occurs during pregnancy; cause is unknown. - classic signs / triads: Proteinuria, Edema, Hypertension. Hypertension and proteinuria are the most significant. - occurs most frequently in primiparas younger than 20 years or older than 40 years, low socio-economic background (with poor nutrition), 5 or more pregnancies, multiple pregnancy, with hydramnios, heart disease, diabetes. - occurs from systemic vascular spasm (from increased cardiac output) affecting all organs. - when vasoconstriction occurs, blood pressure increases dramatically (hypertension). - vasospasm in the kidneys increase blood flow resistance. This results to degenerative changes that lead to increased permeability of the glomerular membrane, allowing serum proteins albumin and globulin to escape into the urine (proteinuria). - The degenerative changes in the kidneys result to increased tubular reabsorption of sodium, because sodium retains fluid, edema results. Classification: 1. Gestational hypertension (previously known as PIH) - the woman develops elevated BP 140/90 mmHg but has no proteinuria or edema. - prone to develop chronic hypertension later in life.

2. Mild preeclampsia - BP rises to 140/90 mmHg, taken on two occasions at least 6 hours apart. The systolic blood pressure is greater than 30 mmHg and diastolic pressure greater than 15 mmHg above prepregnancy values. The diastolic value is extremely important to note because it indicates the degree of peripheral arterial spasm present. - proteinuria of 1+ or 2+ (represents a loss of 1 to 2g of protein in 24 hours). - presence of edema due to protein loss, sodium retention, and lowered glomerular filtration rate. Edema accumulates in the upper part of the body, weight gain of more than 2 lbs/wk in the 2nd trimester or more than 1 lb/wk in the third trimester. * Promote bed rest the best method of aiding an increased evacuation of sodium and encouraging diuresis. Rest should always be in a lateral recumbent position to avoid supine hypotension syndrome. 3. Severe preeclampsia - BP rises to 160/110 mmHg, taken on two occasions at least 6 hours apart on bed rest. The diastolic pressure is more than 30 mmHg above prepregnancy level. - marked proteinuria 3+ to 4+ (represents a loss of 5g of protein in 24 hours) - extreme edema noticeable in the face and hands as puffiness; reports that my rings are so tight that I cant get them off. - cerebral and visual disturbances; marked hyperreflexia; oliguria (500 mL or less in 24 hours) * Promote an undisturbed bed rest (private room in a hospital); a loud noise is sufficient to trigger a seizure initiating eclampsia. - the room should be darkened (bright lights can trigger a seizure). - restrict visitors to support people - monitor BP q4h to detect worsening condition. - assess FHR q4h - moderate to high-protein diet to compensate for the protein loss. - plus administer medications to prevent eclampsia Magnesium sulfate - remains to be the drug of choice to prevent eclampsia. It reduces edema by causing a fluid shift from the extracellular spaces to the intestine. It has a CNS depressant action that lessens the possibility of seizures. * Assessment before administration - urine output should be above 25 to 30 mL / hour - respirations should be above 12 bpm - DTR should be present (patellar reflex or knee jerk) - should be able to answer questions asked of her (consciousness) - 10 mL of 10% calcium (specific antidote) gluconate solution should be kept nearby in case of magnesium toxicity. * Evident sx of overdose - decreased urine output - depressed respirations - reduced consciousness - decreased DTR

4. Eclampsia - the most severe classification of PIH. - cerebral irritation from increasing cerebral edema is so acute that a seizure or coma occurs. High mortality rate due to cerebral hemorrhage, circulatory failure, and renal failure. - temperature rises sharply to 39 to 40C due to increased cerebral pressure - blurring of vision; severe headache; hyperactive reflexes * Maintaining a patent airway is the priority care. - administer oxygen face mask to protect the fetus during this interval - assess FHR - turn the woman to her side to prevent aspiration of secretions Multiple Pregnancy - considered a complication of pregnancy because the womans body must adjust to the effects of more than one fetus. a. Identical (monozygotic twins) - single ovum and spermatozoon; usually have one placenta, one chorion, two amnions, two umbilical cords; the twins are always of the same sex. b. Fraternal (dizygotic, non-identical twins) - result from the fertilization of two separate ova by two separate spermatozoa (possibly not from the same sexual partner). - have two placentas, two chorion, two amnions, two umbilical cords - may be of the same or different sex. * Assessment - uterus begins to increase in size at a rate faster than normal - at the time of quickening, the woman may report flurries of action at different portions of her abdomen. - more susceptible to PIH, hydramnios, placenta previa, preterm labor, anemia - more prone to postpartal bleeding because of additional uterine stretching - prescribed bed rest at home during the last 2 to 3 months of pregnancy to prevent preterm labor. Isoimmunization (RH incompatibility) - if a woman who is Rh negative carries an Rh positive fetus, a blood incompatibility results. People who have Rh positive blood have a protein factor that Rh negative people do not have. - the Rh factor exists as a portion of the red blood cells, therefore, to destroy the antigen, the entire red blood cell must be destroyed. - as the placenta separates after the birth of the child, there is an active exchange of fetal and maternal blood from the damaged villi. - most of the maternal antibodies are formed by the Rh negative woman in the 1st 72 hours after birth. * Management - RhIG (a passive antibody against the Rh factor) is administered to women at 28 wks of pregnancy. It does not cross the placenta late in pregnancy and destroy fetal red blood cells because they are not the IgG class (the only type that crosses the placenta). - it is being given again by injection to the mother in the 1st 72 hours after birth of an Rh positive infant, so that the mother forms no natural antibodies. - because the RhIG is a passive antibody protection, it is transient. In 2 wks to 2 months, the passive antibodies are destroyed.

Indirect Coombs Test - determination if Rh antibodies are present in the maternal serum. - if the titers are not elevated, an Rh negative woman will receive RhIG (RhoGAM) at 28 weeks of pregnancy. Drugs used in PIH: DRUG Magnesium sulfate INDICATION Muscle relaxant; prevents seizures DOSAGE Loading dose 4-6g; maintenance dose 12g/h IV NURSING INTERVENTIONS Infuse loading dose slowly over 15-30 mins.; always administer as piggyback infusion; assess RR, urine output, DTR, clonus every hour; serum magnesium level should remain below 7.5 meq/L; observe for CNS depression and hypotonia in infant at birth Administer slowly to prevent sudden fall in BP Administer slowly; observe for respiratory depression or hypotension in mother and respiratory depression and hypotonia in infant at birth Have it prepared at bedside; administer at 5 mL/min

Hydralazine (Apresoline) Diazepam (Valium)

Antihypertensive (peripheral vasodilator) Halt seizures

5-10 mg/IV 5-10 mg/IV

Calcium gluconate

Specific antidote for magnesium intoxication

1g/IV (10 ml of a 10% solution)

Diagnostic Tests: 1. Maternal Serum Alpha-Fetoprotein analysis - is a glycoprotein produced by the fetal liver that is present in the amniotic fluid or maternal serum. - the level is elevated in maternal serum if the fetus has an open spinal or abdominal defect, because the open defect allows more alpha-fetoprotein to appear. The level is low if the fetus has a chromosomal defect, such as Down Syndrome; the reason is unknown. - traditionally assessed at the 16th 18th week of pregnancy, it is now feasible to analyze this as early as the 11th week of pregnancy (AFP levels begin to rise at 11th week). - the level in serum is expressed as multiples of the mean (MOM). A normal value is 2.5 MOM. 2. Chorionic Villi Sampling - involves the retrieval and analysis of chorionic villi for chromosome analysis. - more commonly done at 8 to 12 weeks; may be done as early as 5 weeks

- carries a small risk (about 2% to 4%) of causing excessive bleeding leading to pregnancy loss. - there also have been high instances of children being born with missing limbs after the procedure (limb reduction syndrome). 3. Amniocentesis - the withdrawal of amniotic fluid through the abdominal wall for analysis - done at 14th to 16th week of pregnancy; can be done as early as the 12th week of pregnancy. Although less amniotic fluid can be removed at this time (only about 2 mL as compared to 5 mL sample obtained later), it is enough fluid for genetic testing (requires 1 mL for analysis). - has the advantage over CVS of carrying only 0.5% risk of spontaneous miscarriage. * ask the woman to void (to reduce the size of the bladder thus preventing puncture. - place the woman in supine position; place a folded towel under her right buttock to tip her body slightly to the left to prevent supine hypotension syndrome. -monitor FHR and maternal BP Color - normal amniotic fluid is like the color of water; a strong yellow color suggests blood incompatibility resulting from the bilirubin released with the hemolysis of rbc; a green color suggests meconium staining, a phenomenon associated with fetal distress. Lecithin / Sphingomyelin Ratio - are the protein components of the lung enzyme surfactant that the alveoli begin to form about the 22nd to 24th weeks of pregnancy. - 2:1 ratio is accepted as lung maturity 4. Percutaneous Umbilical Blood Sampling (PUBS) / Cordocentesis / Funicentesis - is the removal of blood from the umbilical vein for analysis. 5. Sonography / ultrasound - is a diagnostic tool that is helpful in assessing a fetus for general size and structural disorders of the internal organs, spine, and limbs. - may be used concurrently with amniocentesis because it causes no apparent risk to the fetus. - predicts maturity by measurement of the biparietal diameter * the woman should not void before the procedure. A full bladder will help stabilize the uterus and will therefore reflect good sound waves. - drink a full glass of water every 15 minutes beginning an hour and a half before the procedure (6 glasses of water for 1hr and a half) - place a folded towel under her right buttock Biparietal Diameter - predicts fetal maturity by measuring the biparietal diameter (side to side measurement) of the fetal head. - a measurement of 8.5 cm indicates a fetal age of 40 weeks Placental Grading - based on the amount of calcium deposits in the base of the placenta - Grade 0 (placenta at 12 to 24 weeks); Grade 1 (30 to 32 weeks); Grade 2 (36 weeks); Grade 3 (38 weeks) - because fetal lungs are apt to be mature at 38 weeks, a grade 3 placenta suggests that the fetus is mature.

6. Contraction Stress Testing (CST) - the FHR is analyzed in conjunction with uterine contractions. - nipple stimulation (the mother rolls nipple between her finger and thumb until uterine contractions begin), which are recorded by a uterine monitor. - 3 contractions with a duration of 40 seconds or more must be present in a 10-min window before the test can be interpreted. - the test is NEGATIVE (normal) when no FHR decelerations are present with contractions. - the test is POSITIVE (abnormal) when 50% or more of contractions cause a late deceleration. 7. Nonstress Testing - measures the response of the fetal heart rate to fetal movement. - usually done for 10 to 20 minutes - when the fetus moves, the FHR should increase about 15 bpm, remains elevated for 15 seconds; if no increase in FHR on fetal movement, poor oxygen perfusion is suggested. - the test is REACTIVE (normal) if two accelerations of FHR (15 bpm or more) lasting for 15 seconds occur. - the test is NON-REACTIVE (abnormal) if no accelerations occur with the fetal movements. Comparison of Nonstress Test and Contraction Stress Test: ASSESSMENT What is measured Normal findings NONSTRESS Response of FHR to fetal movement REACTIVE; Two or more accelerations of FHR of 15 bpm lasting 15 seconds or more following fetal movements in a 20-min period Place a rolled towel under the right buttock CONTRACTION STRESS Response of FHR in relation to uterine contraction through nipple stimulation NEGATIVE; No late decelerations with contractions

Nursing interventions

Place a rolled towel under the right buttock; observe for 30 min afterward to ensure preterm labor does not begin

Intrapartal Preliminary Signs of Labor: 1. Lightening descent of the fetal presenting part into the pelvis; the process in which the fetus drops into the pelvic outlet. - Primipara (10 to 14 days before labor begins); multipara (day of labor). - relief from the diaphragmatic pressure and shortness of breath; lightens her load. 2. Increase in level of activity - epinephrine release initiated by the decrease in progesterone; prepares the womans body for labor. 3. Braxton Hicks Contractions - extremely strong contractions on the last days before labor begins which may be interpreted as true labor contractions. 4. Goodells sign - ripening of the cervix; from consistency of an earlobe during pregnancy to butter-soft; internal announcement that labor is close at hand.

Differentiation Between False and True Labor: FALSE LABOR Contractions: Braxton-Hicks intensify (more noticeable at night); felt abdominally; short; irregular Relieved by change of position or activity (walking) Cervical changes none; no effacement or dilatation progress TRUE LABOR Contractions: Begins in lower back and radiates to abdomen (girdling), becomes regular n rhythmic; frequency, duration, and intensity increases Unaffected by change of position, activity Cervical changes progressive effacement and dilatation

Three major signs of true labor: 1. Uterine contractions initiation of effective, productive, involuntary uterine contractions. 2. Show the mucus plug that fills the cervical canal during pregnancy is expelled. 3. Rupture of the membranes sudden gush or scanty, slow-seeping fluid from the vagina. Components of Labor: 1. Passage (pelvis) the route that the fetus must travel; must pass through the pelvic ring. - two important pelvic measurements: - diagonal conjugate the antero-posterior diameter of the inlet; the narrowest diameter (11 cm). - transverse diameter of the pelvic outet the narrowest diameter (11cm). 2. Passenger (fetus) the body part that has the widest diameter is the head. - suboccipito-bregmatic diameter the narrowest diameter (9.5 cm) - occipito-frontal 12 cm - occipito-mental the widest (13.5 cm) 3. Powers (uterine factors) supplied by the fundus of the uterus. - labor contractions begin at a pacemaker point in the myometrium. Phases of labor contraction: - increment (intensity of contractions increases) - acme (contraction is at its strongest) - decrement (intensity decreases) - duration of contraction (increment to decrement of the same contraction) - relaxation (decrement of one contraction to increment of the next contraction) - frequency (increment of one contraction to increment of the next contraction); beginning of one contraction to the beginning of the next contraction. Cervical changes: - effacement (shortening and thinning of the cervical canal) - dilatation (enlargement of the cervical canal) - in primiparas, effacement is accomplished before dilatation begins; in multiparas, dilatation may proceed before effacement is complete. 4. Psyche psychological state or feelings of the woman. Fetal Presentation and Position: Attitude

- the degree of flexion the fetus assumes during labor / the relation of the fetal parts to each other. - vertex (complete / full flexion), the head is flexed forward so much that the chin touches the sternum; the normal fetal position.; presents the occipitobregmatic diameter. - sinciput or military position (moderate flexion); presents the occipitofrontal diameter. - brow (partial extension) - face (poor flexion / complete extension); presents the occipitomental diameter. Station - relationship of the fetal presenting part to the level of the maternal ischial spines. - 0 station (at the level of the ischial spines; engagement) minus stations (above the ischial spines; from -1 cm to -4 cm) plus stations (below the ischial spines; from +1 cm to +4 cm); crowning (+3 or +4) Fetal Lie - the relationship of the long axis of the fetal body and the long axis of the womans body. - whether the fetus is lying in a horizontal / transverse or vertical / longitudinal position. Types of Fetal Presentation - denotes the body part that will first contact the cervix or deliver first. 1. Cephalic presentation head is the body part that first contacts the cervix; 95% of the time. 2. Breech presentation either the buttocks or the feet; complete, frank, footling. 3. Shoulder presentation long axis is perpendicular to the mother (transverse lie). Position - the relationship of the presenting part to a specific quadrant of the womans pelvis. 4 quadrants of the maternal pelvis: - right anterior, left anterior, right posterior, left posterior Fetal landmarks: - Occiput for vertex presentation Mentum for face presentation Sacrum for breech presentation Acromion for shoulder presentation LOA the 1st letter defines whether the landmark is pointing to the right or left. The middle letter denotes the fetal landmark. The last letter defines whether the landmark points anteriorly or posteriorly. LOA is the most common fetal position; ROA the second most frequent position; the fetus delivers fastest from an LOA or ROA position. Labor is considerably extended if the position is LOP or ROP; also more painful for the mother because the rotation of the fetal head puts pressure on the sacral nerves. Type of Cephalic Presentations: TYPE Vertex Brow LIE Longitudinal Longitudinal ATTITUDE Good (full flexion) Moderate (military) DESCRIPTION Vertex is the presenting part; suboccipito bregmatic Sinciput is the presenting part;

Face Mentum

Longitudinal Longitudinal

Poor Very poor

suboccipitofrontal Face is the presenting part; occipitomental Chin is the presenting part; occipitomental

Cardinal Movements (Mechanisms) of Labor: - number of different position changes to keep the smallest diameter of the fetal head always presenting to the smallest diameter of the birth canal. 1. Descent head engages and proceeds down the birth canal. 2. Flexion head bent to chest; presents the smallest diameter of vertex. 3. Internal Rotation the head flexes as it touches the pelvic floor, and the occiput rotates until it is superior, bringing the head into the best diameter for the pelvic outlet. 4. Extension as the occiput is born, the head thus extends and the foremost parts of the head are born. 5. External Rotation / Restitution the head rotates back to the diagonal or transverse position of the early part of labor; the anterior shoulder is born first. 6. Expulsion birth of the neonate completed. Stages of Labor: 1. 1st Stage stage of dilatation; beginning with true labor contractions and ending when the cervix is fully dilated. a. Latent phase - begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins. - the woman can and should continue to walk about and make preparations for birth. b. Active phase show (increased vaginal secretions) and rupture of membranes may occur. c. Transition phase the woman experiences intense discomfort, accompanied by nausea and vomiting. Her focus is entirely inward on the task of birthing the baby. 2. 2nd Stage the period from full dilatation and cervical effacement to the birth of the infant; the woman pushes with such force that she perspires and the blood vessels in her neck may become distended. 3. 3rd Stage the placental stage; begins with the birth of the infant and ends with the delivery of the placenta. Maternal Progress in 1st Stage of Labor: CRITERION Cervical dilation Contractions: Strength Duration Frequency Rhythm Behavior LATENT 0 3 cm Mild and short 20 to 40 seconds 6-8h nullipara 4-5h multipara 5 30 minutes apart Irregular Excited, talkative, alert, ACTIVE 4 7 cm Moderate 40 to 60 seconds 3-5h nullipara 2h - multipara 3 5 minutes apart More regular Becomes more serious, TRANSITION 8 10 cm Strong 60 to 90 seconds 1h nullipara 25 mins - multipara 2 3 minutes apart Regular In severe pain, fear of

follows directions

desires companionship, some difficulty following directions

loss of control, vague in communications, anxiety, panic, irritability

Placental Separation: Signs: - lengthening of the umbilical cord; sudden gush of vaginal blood; change in the shape of the uterus. (Placenta separates approximately 5 mins after the birth of the infant) Schultze placenta shiny and glistening (the fetal membrane surface); 80% Duncan placenta dirty (raw, red, irregular maternal surface). Credes maneuver gentle pressure on the contracted uterine fundus. Pressure must never be applied to uterus in a non-contracted state or the uterus may evert and hemorrhage. 300 to 500 mL average amount of blood loss with birth; is not detrimental to the woman because of the blood volume increase that occurs during pregnancy. WBC 25,000/mm3 to 30,000mm3 as compared to normal 5,000/mm3 to 10,000/mm3. Leopolds Maneuvers: - a systematic method of observation and palpation to determine fetal presentation and position. - instruct client to empty bladder (promotes comfort; fetal contour will be obscured by a distended bladder). - supine position with knees slightly flexed; place a small pillow or rolled towel under one side. (relaxes the abdominal muscles, tilts the uterus off the vena cava to prevent supine hypotension syndrome). - wash hands with warm water (prevents spread of infection; prevents tightening of abdominal muscles). 1. 1st maneuver determines the presenting part at the fundus. - place both hands flat on abdomen; head feels more firm than breech; head is round and hard; breech is less defined. 2. 2nd maneuver locates the fetal back. - palms of each hand on either side of the abdomen; one hand will feel a smooth, hard, resistant surface (back) while on the opposite side, a number of angular nodulations (knees and elbows of the fetus) will be felt. 3. 3rd maneuver determines the part of the fetus at the inlet and its mobility (engagement). - grasp lower portion of abdomen between thumb and finger, if the presenting part moves upward so an examiners hands can be pressed together, it is not yet engaged. 4. 4th maneuver determines fetal descent. - place fingers on both sides of the uterus approximately 2 inches above the inguinal ligaments, pressing downward and inward in the direction of the birth canal. Fetal Heart Rate Patterns: Baseline FHR - determined by analyzing a range of fetal heartbeats recorded on a 10-minute tracking that is obtained between contractions. A normal rate is 120 to 160 bpm. - fetal bradycardia occurs when the FHR is below 120 bpm for 10 minutes. Fetal tachycardia occurs when the rate is 160 bpm or more for a 10 minute period.

FHR fluctuations - occur in response to contractions and fetal movement 1. Accelerations abrupt increase in FHR above the baseline rate. The increase is 15 bpm or more lasting for 15 seconds or more, returns to baseline in less than 2 minutes from the beginning of the acceleration. - caused by dominance of the sympathetic nervous response and are usually encountered with breech presentations. Pressure of the contraction applied to the fetal buttocks results in accelerations, whereas pressure applied to the head results in decelerations. 2. Decelerations caused by dominance of parasympathetic stimulation in response to vagal nerve compression that brings about a slowing of FHR. Early decelerations gradual decrease in FHR which results from fetal head compression. It follows the pattern of the contraction, beginning when the contraction begins and ends when the contraction ends. Late decelerations decelerations that are delayed until 30 to 40 seconds after contraction has started and continue beyond the end of the contraction. This is an ominous pattern of labor because it suggests uteroplacental insuffiency or decreased uterine blood flow. - may occur with abnormal uterine tone caused by oxytocin administration; stop or slow the rate of administration. - change the womans position from supine to lateral; to relieve pressure on the aorta and vena cava and to supply more blood to the uterus. Variable decelerations decelerations that occur at unpredictable times in relation to contractions; they indicate compression of the cord. - tends to occur more frequently after rupture of the membranes that leads to prolapsed cord; or with oligohydramnios. - change the womans position from supine to lateral, or to a Trendelenburg position to relieve pressure on the cord. EARLY LATE VARIABLE ACCELERATION DECELERATION DECELERATION DECELERATION Description FHR above FHR concurrent FHR after onset FHR that varies baseline rate with contractions of contraction in duration, intensity, timing Cause Spontaneous fetal Head Uteroplacental Umbilical cord movement, compression insufficiency compression uterine resulting from: caused by: caused by: contractions, Uterine Uterine Short cord, vaginal contraction, hyperactivity, prolapsed cord, examination, vaginal maternal supine nuchal cord breech, fundal examination, hypotension, pressure, fundal pressure epidural or spinal abdominal anesthesia, palpation placenta previa, abruptio placenta, hypertensive disorders Clinical Fetal well-being, Reassuring pattern Non-reassuring Non-reassuring significance fetal alertness not associated with pattern associated pattern associated fetal hypoxemia with fetal with fetal

Nursing interventions

None required

None required

hypoxemia Change maternal position to lateral, increase rate of IV, O2 at 8 to 10 L/min, discontinue oxytocin

hypoxemia Change maternal position (side to side), O2 at 8 to 10 L/min, discontinue oxytocin

Narcotic Analgesics for Labor: DRUG Meperidine Hydrochloride (Demerol) Nalbuphine (Nubain) Butorphanol Tartrate (Stadol) Fentanyl (Sublimaze) Morphine sulfate USUAL DOSAGE / ROUTE 25 mg IV; 50100 mg IM q3-4h EFFECT ON MOTHER Feeling of euphoria and wellbeing Slows respiratory rate Withdrawal sx if woman is opiate dependent Hypotension, respiratory depression Pruritus EFFECT ON LABOR PROGRESS Slows labor contractions if given early Mild maternal sedation Slows labor if given early Slows labor if given early Slows labor EFFECT ON FETUS / NEWBORN Should be given 3h b4 delivery to avoid respiratory depression in newborn Some respiratory depression Some respiratory depression Respiratory depression Has minimal effect

10-20 mg IM q36h; 0.3-3mg/kg over 10-15min IV 1-2 mg IM or IV q3-4h 50-100 ug IM or 25-50 ug IV Intrathecal 0.2-1 mg; 5 mg epidurally 0.01 mg/kg via umbilical vein, SC, or IM

Naloxone Hydrochloride (Narcan)

Hypertension, hypotension, tachycardia, diaphoresis

Narcotics often given in labor because of their potent analgesic effect (reduces pain awareness). All the drugs in this category cause fetal CNS depression because it cross the placenta. - the drug crosses the placenta minutes after IM or IV administration. The fetal liver takes 2 to 3 hours to activate the drug into the fetal system. - Demerol is given when the mother is 2 to 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth. * When a narcotic is given during labor, a narcotic antagonist such as Naloxone (Narcan) should be available for administration to the infant at birth.

Postpartal Period Postpartal period puerperium; 6-week period after childbirth. - a time of maternal changes that are retrogressive (involution of uterus and vagina), and progressive (production of milk for lactation, restoration of the normal menstrual cycle, and beginning of the parenting role). - Fourth trimester of pregnancy. - First hour postpartum is an extremely dangerous period for hemorrhage; the optimum period when breastfeeding should begin. Phases of the puerperium: (Reva Rubin) 1. Taking-in phase - first 2 or 3 days - time of reflection for the woman; largely passive and dependent - talkative, verbally relieves labor / birth experience - physical discomforts from perineal stitches, afterpains, uncertainty caring for the newborn, extreme exhaustion, expresses little interest in caring for the child - wants to talk about her pregnancy, labor and childbirth, needs time to rest and regains her physical strength - encouraging the woman to talk and to elaborate on her story is therapeutic. 2. Taking-hold phase - 3 days to 2 weeks but varies - independent, begins to initiate action, makes her own decisions, takes a strong interest in caring for her child, assumes the mothering role - best time for health teachings, always best to give the woman a brief demonstration of baby care, allow to care for child herself - give positive reinforcement 3. Letting-go phase - redefines her new role, gives up the old role of being childless or the mother of only one or two children - bonding process is facilitated and parenting skills enhanced - time when postpartum blues develop (feelings of overwhelming sadness for which they cannot account, bursts into tears easily; due to hormonal changes, evidenced by tearfulness, mood lability, anorexia, sleep disturbance) - reassurance that sudden crying episodes are normal and supportive care should be given Physiologic changes Reproductive Involution reproductive organs return to their non-pregnant state 1. Uterus contractions (main mechanism) reduces the size from being a container large enough to hold a full-term fetus to one the size of a grapefruit. - the involution is complete by 6 weeks, from 1000g to 50g weight (pre-pregnant weight) fundal height: - level of umbilicus (delivery day, 1 hour after birth) - level decreases one fingerbreadth (1 cm) a day - 10th day, uterus has withdrawn into the pelvis and can no longer be detected by abdominal palpation.

Lochia is the uterine flow consisting of blood, fragments of deciduas, white blood cells, mucus, and some bacteria. - amount: moderate (4 8 pads/d; average 6 pads/d). - odor: normal lochia has characteristic fleshy odor; foul odor is characteristic of infection. - clots: normal is few small clots; clots and heavy bleeding is associated with uterine atony or retained placental fragments. Characteristics of lochia: TYPE Lochia rubra Lochia serosa Lochia alba COLOR Red Pink / brownish Colorless / white DURATION 1 to 3 days 3 to 10 days 10 14 days COMPOSITION Blood, particles of deciduas, mucus Blood, mucus, leukocytes Mucus, high leukocyte count

PPH loss of more than 500mL of blood after vaginal birth and 1000mL of blood after cesarean birth. Uterine atony marked hypotonia of the uterus, uterus has become relaxed - is the leading cause of postpartum hemorrhage associated with high parity, hydramnios, macrosomic fetus, multifetal gestation. The uterus is overstretched and contracts poorly after birth. Inversion of the uterus the uterus is turned inside out. - contributing factors: - vigorous fundal pressure, excessive traction applied to the cord, abnormally adherent placental tissue. - primary presenting signs: hemorrhage, shock, pain. - NI: do not pull the umbilical cord strongly unless the placenta has definitely separated. Precipitate Labor labor that is completed in fewer than 3 hours. Such rapid labor is likely to occur with multiparity. - contractions may be so forceful they lead to premature separation of the placenta, placing the mother and the fetus at risk for hemorrhage. - poses a risk to the fetus because subdural hemorrhage may result from the sudden release of pressure on the head. The woman may sustain lacerations of the birth canal from the forceful birth. Uterine rupture when it undergoes more strain than is capable of sustaining. It occurs most commonly when a vertical scar from a previous cesarean birth tears. - contributing factors: prolonged labor, multiple gestation, unwise use of oxytocin. - impending rupture is preceded by a pathologic retraction ring (an indentation apparent across the abdomen over the uterus) and strong uterine contractions without any cervical dilatation. - to prevent rupture when sx are present, anticipate the need for immediate cesarean birth. It is an immediate emergency situation because the uterus is highly vascular organ. Drugs used to manage PPH: OXYTOCIN (PITOCIN) Action Side effects Contraction of uterus Water intoxication; antidiuretic METHYLERGONOVINE (METHERGINE) Contraction of the uterus Hypertension; nausea; vomiting;

Contraindications Dosage; route

Nursing considerations

effect (diminished output); nausea; vomiting None for PPH 10 IU / 1mL 40 IU/L diluted in lactated Ringers solution or normal saline at 125 to 200 mU/min IV; 10 to 20 U IM Continue to monitor vaginal bleeding and uterine tone

headache Hypertension, cardiac disease 0.2 mg IM q2-4h up to five doses; 0.2 mg IV only for emergency Check BP before giving; do not give if > 140/90 mmHg; continue to monitor vaginal bleeding and tone

* Oxytocin is administered IV so its effect can be quickly discontinued to avoid hyperstimulation. Because of the short half-life of oxytocin (3mins), stopping the flow rate almost immediately stop the oxytocin effect. - when administering, piggyback the solution with a maintenance IV 5% dextrose and water. - observe that contractions occur no less than 2 minutes apart and no longer than 70 seconds duration; anticipate the need to administer Terbutaline in case of hyperstimulation. It decreases myometrial activity, reducing hypertonic uterine contractions.

Postpartum infection any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion or childbirth. - presence of a fever of 38C or more on two successive days of the first 10 postpartum days. Endometritis the most common cause of postpartum infection. - bacterial invasion of the birth canal; It usually begins as a localized infection of the lining of the uterus but can spread to involve the entire endometrium. - fever greater than 38C, increased pulse, chills, anorexia, nausea, malaise, pelvic pain, uterine tenderness, boggy uterus, foul-smelling profuse lochia. - management consists of intravenous broad-spectrum antibiotic therapy (cephalosporins, penicillins, clindamycin, gentamycin); supportive care includes hydration (force fluids), rest and pain relief; encourage Fowlers position to promote drainage. - continuous assessments of lochia and vital signs during treatment. 2. Cervix is soft and malleable immediately after birth. - after a week, the internal os will close as before, but the external os will usually remain slightly open after a vaginal birth; now appears slitlike or stellate (star-shaped) when previously it was round. 3. Vagina takes the entire postpartal period to involute by contraction; the vaginal outlet will remain slightly more distended than before. Urinary System - urinary retention is experienced as a result of loss of bladder tone due to the pressure of the fetal head after a vaginal birth; loss of sensation of having to void after an epidural or spinal anesthetic administration. - diuresis is experienced within the first 12 hours after delivery, daily output 3000 mL. Circulatory System

- A four-point decrease in hematocrit (proportion of RBC to plasma) from 37% to 33% with blood loss. - 1g decrease in hemoglobin value from 11g to 10g/dL. - increase in the number of leukocytes / WBC in the blood as high as 30,000/mm3. Integumentary System - stretch marks on the abdomen (striae gravidarum) appears reddened after birth - excessive pigment on the face and neck (chloasma) and on the abdomen (linea nigra) will be barely detectable in 6 weeks time. Vital Signs - T (a slight 1o increase in temperature during the 1st 24 hours of the puerperium due to dehydration that occurred during labor). If oral temperature rises above 38C excluding the 1st 24 hours, a postpartal infection should be suspected. - P (slightly lower than normal). The increased stroke volume after birth reduces the pulse rate to between 50 and 70 bpm (physiologic bradycardia). - BP (monitor carefully during the postpartal period because it can indicate bleeding). It should be compared with that of her pre-pregnancy level. Lactation (formation of breast milk) - colostrum (yellowih) is the thin, watery, pre-lactation secretion during the 1st 2 days postpartum; have antibiotic, immunologic, and nutritive value. - breast milk forms on the 3rd day; bluish white is the typical color of breast milk. - breast milk forms in response to the decreased estrogen and progesterone causing an increase in prolactin to stimulate milk production. - if the woman is not breastfeeding, she can expect her ovulation at 4 6 weeks and menstrual flow to return in 6 to 10 weeks after birth; if she is breastfeeding, menstrual flow may not return for 3 or 4 months. Breastfeeding: - Prolactin is released from APG; Oxytocin is released from PPG and cause let-down reflex. - wash breast daily without using soaps - Calories should be increased to 3,000 per day or additional 500 to normal caloric needs / day - Additional 1000mL fluids; 3000 mL daily