External Structures

• Mons pubis – rounded fatty pad; pubic hair

• Labia majora – fatty fold of skin; covers labia minora
• Labia minora – with glands; rich nerve supply
• Clitoris – erectile tissue; abundant nerve endings
• Vestibule – space between the labia minora
1. urethral opening
2. Skene’s glands – secrets mucus
3. Bartholin’s glands – secretes mucus during arousal
4. vaginal orifice
• Perineum – area between vaginal opening and anus
 Internal Structure
• Fallopian tubes –
passageway of ova
• Uterus
 fundus
 corpus
 isthmus
 cervix
• Ovaries – almond
shaped organs; ova and
hormones
• Vagina – birth canal
 Pelvic Shapes
Gynecoid
- wide and well rounded
- female pelvis
• Android
 - narrow, heart shaped
 - male pelvis
• Anthropid
- oval shaped
• Platypelloid
- wide but flat
 Pelvic Divisions
False Pelvis
Above the pelvic brim

True pelvis
• below the pelvic brim
• pelvic inlet, pelvic cavity
and pelvic outlet
• influence the progress
of labor and delivery
 Pelvic Measurements
True conjugate- upper margin of symphysis pubis
to sacral promontory; 11cm
Diagonal conjugate – lower border of symphisis
pubis to sacral promontory; 12.5 – 13cm
Obstetric conjugate – most important
measurement; inner surface of symphysis pubis
to sacral promontory; 1.5 – 2cm less than
diagonal conjugate
Bi-ishial diameter – between the ischial
tuberosities atleast 8cm
 The Breasts Breast profile:
Anterior chest wall A - ducts
between the 2nd and 6th B - lobules
C -dilated section
ribs
of duct to hold
• Glandular tissue, fat and milk
connective tissue D -nipple
E -fat
• Prolactin and oxytocin
F -pectoralis
• Nipple and areola major muscle
become darker in color G -chest wall/rib
during pregnancy cage

Enlargement:
A -normal duct
cells
B -basement
membrane
 Menarche
• First menstration

• Onset of the menstrual cycle

• Normal range: 9 to 17 years old

 Menstrual Cycle
• Regularly recurring process that controls the
ripening and release of an ovum with the
accompanying
changes in the endometrium

• Interaction of the pituitary gland, ovaries and

the uterus

• Average length: 28 days

 Menstrual Cycle:
Hormones
Follicle Stumulating Hormones (FSH)
- growth and development of the ovum
Luteinizing Hormone (LH)
- ovulation
Estrogen
- proliferative phase of the menstrual cycle
Progesterone
- secretory phase of the menstrual cycle
Menstrual Cycle: Phase
Menstruation: 1st day of the menstrual cycle;
shedding of the endometrium

Proliferative Phase: thickening of the

endometrium;
estrogen

Secretory Phase: development of the endometrial

glands and blood vessels; progesterone
 Menopause
Climacteric

Decline ovarian function and hormone

production

Menstrual irregularity, vasomotor instability,

loss of bone density
Female Sexual Response
Excitement Phase – vaginal lubrication and
congestion of genital blood vessels

Plateau Phase – formation of orgasmic platform

in the vagina

Orgasmic Phase: strong rhythmic vaginal and

uterine contractions

Resolution Phase: return to previous condition

Fertilization
Union of the sperm and
ovum

Occurs within 12 hours of

ovulation and within 2-3
days of insemination

Upper third of the

Fallopian tube

Sperm: XY chromosome
Ovum: XX chromosome
Implantation
Nidation

6-8days after fertilization

Upper portion of the uterus

Human Chorionic
Gonadotropin (HCG) –
from the trophoblast;
basis of pregnancy test
Developmental
Stages
Zygote: fertilized
ovum

Embryo: end of the

second week to the
end of the eight week

Fetus: end of the

eighth week to term
Fetal Structures
Fetal Membranes

Hold the developing fetus

and amniotic fluid

Chorion – outer vascular

membrane

Amnion – inner membrane;

forms the amniotic sac
Amniotic Fluid
500 to 1000 ml;
alkaline Ph

Functions:
1.Protects fetus
2.Allows fetal
movements
3.Maintains fetal body
temperature
Placenta
Develops by the third
month
Exchange of nutrients
and waste products
beyween mother and
fetus
Immuneglobulin G
(IgH)
Hormones
Umbilical Cord
Connects fetus and the
placenta
Length: 20 inches
2 arteries and 1
vein: umbilical
arteries –
deoxygenated blood
Veins – oxygenated
blood
Physiologic Changes During
Pregnancy
Reproductive System

Increased vascularity of the genitalia

Amenorrhea
Increased vaginal secretion; changes in vaginal pH
Softening and discoloration of the cervix
Enlargement and change in uterine shape
Braxton Hicks contractions
Increase and breast size
Chadwick’s Sign: bluish discoloration of the
vulva and vagina

Goodell’s Sign: softening of the cervix

Hegar’s Sign: softening of the uterine isthmus

Cardiovascular System
Increased blood volume by 40-50%
Greater tendency to coagulation
Increase stroke volume and cardiac 0utput
Increase heart size and heart rate
Decreased blood pressure (second trimester)
Sodium and water retention
Respiratory System
Increase in oxygen consumption
Increase respiratory volume
Shortening of the thorax
Increased vascularity of mucus membranes ->
nasal
And pharyngeal congestion
Shortness of breath (last trimester)
Gastrointestinal System
Increased HCG levels
Alterations in taste and smell
Increased salivation
Heartburns
Gum bleeding
Decreased intestinal motility
Renal System
Increased renal filtration rate
Decreased renal threshold
Water retention
Decreased bladder capacity and bladder tone
Frequency of urination
Endocrine System
Increased basal metabolic rate (BMR)
Increased body weight (1st trimester: 1-4
pounds; 2nd to 3rd trimester: 1 pound per week)
Increased activity of the thyroid gland
Decreased secretion of LH and FSH
Oxytocin secretion during labor and delivery
Progesterone secreted by corpus luteum until
formation of placent
Musculoskeletal System
Change in posture and walking gait
Backache
Increased joint mobility
hypocalcemia
Integumentary System
Increased skin pigmentation:
a.Linea nigra – midline of the abdomen
b.Chloasma – forehead, cheeks and nose
c.Areola and nipples
Stretch marks (striae) – abdomen, breast,
thighs
Decreased hair growth
Pscchological Changes
During Pregnancy
Ambivalance

Acceptance

Emotional Changes

Body image Changes

Discomfort Associated with
Pregnancy
Nausea and Vomiting

1st trimester Interventions:

Increased HCG levels - Small, frequent,
lowfats meals
- Avoid fried foods
- Avoid antiemetics
during pregnancy
Heartburn
2nd and 3rd trimesters Interventions:
Displacement of the - Small frequent meals
stomach, decreased - Avoid fatty and spicy
intestinal motility food
and esophageal - Remain upright for
reflux 30 minutes after
meals
- Use antacid only as
directed by physician
Fatigue
1st and 3rd trimesters Interventions:
Hormonal changes - Regular exercise
- Frequent rest
perionds
- Avoid food and
drinks containing
stimulants
Varicose Veins
2nd and 3rd trimesters Interventions:
Venous congestion - Elevate feet when
and weakening of sitting
the walls of the veins - Avoid leg crossing
- Avoid long periods of
standing
- Avoid constrictive
clothing
Constipation
2nd and 3rd trimesters Interventions:
Decreased intestinal - High fiber diet (fruits
motility and and vegetables)
displacement of the - Increase fluid intake
intestine - Regular exercise
- Avoid laxatives
Backache
2nd and 3rd trimesters Interventions:
Increased lordosis due - Observe proper
to enlarged uterus posture and body
mechanics
- Wear low heeled
shoes
- Firm mattress
- exercise
Gravida
Number of pregnancy regardless of the
duration; includes present pregnancy

Nulligravida: woman who has never been

pregnant
Primigravida: woman who is pregnant for the
first time
Multigravida: woman who is pregnant two or
more times
Para
Number of times a woman has given birth
(beyond 2o weeks) regardless of outcome

Nullipara: woman who has never given birth

Primipara: woman who has given birth for the
first time
Multipara: woman who has given two or more
times
Naegele’s Rule
Used for estimating the expected date of
confinement (EDC)
Formula:
subtract: 3 from the month of the LMP
add: 7 to the first day of the LMP
Example: LMP – April 2
4–3=1
2+7=9
EDC: January 9
Signs of Pregnancy
Presumptive Sign
Amenorrhea
Nausea and vomiting
Increased urinary frequency
Enlargement of breasts
Vaginal discoloration
Quickening (16th -18th week)
Probable Signs
Enlargement of the uterus
Chadwick’s sign, Goodell’s sign and Hegar’s
sign
Braxton Hick’s contractions
Ballotment
Positive pregnancy test
Positive Signs
Fetal heartbeat (Doppler: 10-12wks and
fetoscope: 18-20 wks)
Palpable active fetal movements
Palpable fetal outline
Demonstration of fetal outline (ultrasound: 6th
wk or
X ray: 12th wk)
Measurement of Fundal
Height
To evaluate gestational age
18-32 weeks:
fundal height (in cm) = fetal age (in weeks)
16 weeks:
fundal halfway between symphisis pubis and
umbilicus
20-22 weeks:
fundus at the umbilicus
36 weeks:
fundus at the xiphoid process
Prenatal Care
First visit:
As soon as the woman suspects she is pregnant
After first missed period

Subsequent visits:
1 – 8 months: monthly
8th month: every 2 weeks
9th month: weekly
Maternal Risk Factors
Infectious Disease
German Measles (Rubella)
- deafness, cataracts, cardiac defects
Syphilis
- spontaneous abortion, physical
abnormalities, mental retardation
Gonorrhea
- neonatal conjunctivitis, pneumonia, sepsis
HIV
Maternal Risk Factors
Substance Abuse
Smoking
- LBW, prematurity, still birth, SIDS
Alcohol
- fetal death, FAS, IUGR,
Marijuana
- LBW, prematurity, tremors, sensitivity to light
Cocaine
- LBW, still birth, tremors, irritability, tachycardia
Pregnancy and Maternal
Disease
Cardiac Disoders Clinical presentation
congenital heart - Cough
disease, rheumatic - Difficulty of
heart disease breathing
- Fatigue
increased blood - Palpatations
volume and increase - Rales, murmurs
cardiac output
- Tachycardia
- edema
Diagnostics Management
- Chest X ray - Digitalis
- EKG - Diuretics
- Echocardiography - Antiarrhythmics
- Anticoagulant
- antibiotics
Nursing Consideration
a. Prepartum
- Provide adequate rest
- Limit sodium intake
- Limit weight gain to 15lbs
- Avoid exposure to infections
b. During labor:
- Monitor maternal VS and FHT
- Administer oxygen and pain medication sa
ordered
- Side-lying or semi-Fowler’s position
- Watch out for signs and symptoms of heart
failure
- Provide emotional support
c. Postpartum
- monitor VS, I&O, weight, bleeding
- Bed rest
- Assist with ADL
- Prevent infection
Diabetes Mellitus
more difficult to control during pregnancy

changes in insulin requirement during pregnancy

- First trimester: decrease
- Second trimester: increase
- Third trimester

Infant of diabetic mother is at risk for hypoglycemia,

RDS, congenital defects and stillbirth
 gestational diabetes occurs in the 2nd or 3rd
trimester

factors predisposing to gestational DM:

- Age (>35 years old)
- Obesity
- Multiple gestation
- Family history

screening: 26th week of pregnancy

Clinical Presentation Diagnostics
- Polyuria - Glucose challenge
- Polydypsia test
- Polyphagia - Oral glucose
- Weight loss tolerance test
- HbA1C
- Frequent UTI
- Large fetus
Glucose Challenge OGTT
Test
confirmatory test
screening test (24-28 3 days high
wks AOG) 100g glucose load
no need for 3 BG determination
preparation and abnormal if:
fasting FBS - > 95 mg/dl
50g glucose load 2 values > 145 mg/dl
normal: <140 mg/dl
Management Nursing considerations
1.Diet - Instruct client
2.Exercise regarding
3.Insulin 1.Diet
2.BG monitoring
3.Complications
- Monitor weight, signs
of infection,
preeclampsia
- Assess fetal status
- Assess insulin needs
Anemia

hemoglobin <10 mg/dl Effects

or hematocrit <20% 1.Preterm birth
most common medical 2.SGA
problem during
3.Increased risk of post
pregnancy
partum infection and
causes hemorrhage
1.Iron deficiency
2.Folic acid deficiency
Clinical presentation Management
- Pallor - Iron supplement
- Fatigue - Vitamin C
- Dizziness - Folic acid
- Shortness of breath supplement
- palpitations
Nursing considerations
- Check hemoglobin and hematocrit levels
every 2 weeks
- Encourage intake of diet rich in iron and folic
acid
- Teach client regarding effects of iron ingestion
- Assess the need for injectable iron
Tuberculosis

droplet infection Clinical presentation

perinatal 1.Mother
transmission is rare 2.Neonate
acquired by - lethargy, poor suck,
swallowing infected failure to thrive,
amniotic fluid respiratory distress,
hepatosplenomegaly
Diagnostics
- mother:
skin test (safe during pregnancy)
chest X ray (abdominal shield)
sputum examination

- neonate:
skin test at birth and repeated at 3 – 4 months
bacilli in gastric aspirate or placental tissue
Management

- mother:
Multidrug therapy (INH, RIF, EMG) for 6-12
mos
- neonate:
INH for 3 mos (mother with active TB)
BCG
Nursing considerations
- Teach mother and family members regarding
transmission and prevention
- Promote breastfeeding only if the mother is
noninfectious
- Mother taking anti TB drugs may breastfeed
the infant
- During active disease, isolate and separate
the infant from the mother
DIC

consumption Predisposing factors

coagulopathy - Abruptio placenta
Increased clot - Amniotic fluid
formation - Embolism
in the circulation due - Dead fetus
to overstimulation of - PIH
the clotting process
- H mole
- Hemorrhagic shock
Clinical presentation Diagnostics
- Uncontrolled - Decreased platelet
bleeding count
- Petechiae, purpura, - Prolonged PT and
ecchymoses PTT
- Hematuria - Prolonged clotting
- Hematamesis time
- shock
Fetal Diagnostic Tests
Ultrasound

uses:
- Validation and dating
of pregnancy
- Assessment of fetal
growth and viability
- Measurement of fluid
volume
safe for fetus
Amniocentesis

aspiration of amniotic
fluid
after the 14th week
uses:
- Identify chromosomal
abnormalities
- Determine fetal sex
Alpha-Fetoprotein Screening

sample used: amniotic fluid

done between 15 and 18 weeks
uses:
- To detect presence of neural tube defects and
chromosomal abnormalities
Lecithin/Sphingomyelin Ratio

(L/S Ratio)
sample used: amniotic fluid
use: to determine fetal lung maturity
normal results at 35-36 weeks: 2:1 (low risk for
developing respiratory distress syndrome)
Chorionic Villi Sampling

use: to obtain tissue

sample at implantation
site
fetal chromosomal, DNA or
metabolic abnormalities
transabdominal or
transcervical
earliest test possible on
fetal cells
between 9 – 12 weeks of
gestation
Danger Signs of
Pregnancy
any form of vaginal bleeding
sudden gush of fluid from the vagina
presence of regular contractions before the
expected date of confinement
severe headache and visual disturbance
facial edema
intractable vomiting
epigastric pain
fever and chills
Complications of
Pregnancy
Abortion

termination of pregnancy before the age of

viability
spontaneous or induced
clinical presentation
- Vaginal bleeding
- Contractions
- Passage of fetus/placental tissue
Type of Abortion
Threatened – contractions/bleeding, cervix closed,
fetus not expelled
Inevitable – cervix open, heavier bleeding
Complete – all products of conception expelled
Incomplete – membrane or placental tissue
retained
Missed – fetus dies in uterus but is not expelled
Habitual – three consecutive pregnancies ending
in spontaneous abortion
Nursing considerations
- Maintain client on bed rest
- IV fluids
- Instruct client to keep all tissues passed
- Prepare client for D & C or suction eveat
Incompetent Cervix
• Pailess dilatation of the cervix in the absence
of uterine contractions; due to cervical trauma
• History of repeated abortions
• Management
- Cerclage
- Shirodkar Technique/ McDonals Procedure
Nursing considerations
- Bed rest
- Monitor VS, fetal heart rate
- Prepare for procedure
- Monitor post-complications:
1.Rupture of membranes
2.Contractions
3.bleeding
Ectopic Pregnancy
 Pregnancy outside the
uterine cavity
 Fallopian tubes – most
frequent site; ruptures
before the 12th week AOG
 Clinical presentation
- Bleeding
- Hypotension
- Abdominal pain and
abnormal pelvic mass
- Decreased hemoglobin and
hematocrit; leucocytosis
Management
- surgery: salpingostomy; salpingectomy
- Blood transfusion
Nursing considerations
- Obtain vital signs
- Monitor bleeding
- Prepare patient for surgery
- Allow client to express feelings about loss of
pregnancy
Hyperemesis Gravidarum
Intractable nausea and vomiting that last
beyod the first trimester
Most pronounced upon waking up
Clinical presentation
- Persistent nausea and vomiting
- Dehydration
- Electrolyte imbalance
- Weight loss
Nursing considerations
- Monitor vital signs, fetal heart rate and fetal
activity
- Monitor I&O, electrolytes and hematocrit
- Small feedings
- Dry diet, alternate liquids and solids
- Weight patient daily
- Assess fetal growth
Hydatidiform mole
 Developmental anomaly of
placenta
 Grape-like clusters
 Common in women over 40
 Clinical presentation
- Increasing size of uterus
- Increased levels of HCG
- Vaginal bleeding
- Absent fetal heart sounds
- Ultrasound: snowstorm
pattern
Management
- Evacuation of the uterus (suction curretage)
- Hysterectomy
- chemothearapy

Nursing considerations
- Instruct patient to monitor HCG levels for 1 year
- Teach patient how to use contraceptives to delay
pregnancy by at least a year
Prenancy-Induced Hypertension
Vasopastic hypertesion, edema and proteinuria
Onset: after 20th week of pregnancy
Classification:
1.Preecclampsia (mild or severe)
2.Eclampsia
Management: termination of pregnancy
Complication: HELLP syndrome (hemolysis,
elevated liver enzymes, low platelet count)
Mild Preeclampsia
Onset: between 20th and 24th week of pregnancy
Hypertension of 15-30 mmHg above the baseline
Sudden weight gain (1 lb/wk), edema of the hands and
face, (+1) protenuria
Nursing considerations:
- Bed rest in left position
- Monitor blood pressure, weight, deep tendon reflexes
- Increase dietary carbohydrate and protein
Severe Preeclampsia
Blood pressure of 150/100 – 160/110
Headache, epigastric pain, nausea and vomiting,
visual disturbance
(+4) protenuria, oliguria, hyperreflexia
Management: magnesium SO4, hydralazine
Nursing considerations:
- Daily funduscopic examinations; monitor reflexes
- Seizure precautions
- Continue to monitor 24 -48 hours post partum
Eclampsia
C0nvulsions, coma, cyanosis, fetal distress
Bp > 160/110, severe edema, 4+ proteinuria
Nursing considerations:
- Administer oxyden
- Minimize all stimuli
- Seizure precautions
- Monitor vital signs
- Prepare for C section
Placenta Previa
Abnormal
implantation of the
placenta in the lower
uterine segment
Classification
1.Complete (total,
central)
2.Partial
3.Marginal (low lying)
Clinical presentation
- Painless vaginal bleeding (third trimester)
- Abnormal fetal position
- anemia
Management
- Based on maternal and fetal condition
1.Conservative
2.Cesarian section
Nursing considerations
- Bed rest
- IV fluids
- Blood transfusion as needed
- Monitor vital signs, FHR, fetal activity
- Avoid vaginal examinations
- Prepare for ultrasound
- Prepare for cesarian section
Abrputio Placenta
Premature separation of a
normally implanted
placenta
Risk factors
- Maternal hypertension
- Short umbilical cord
- Abdominal trauma
- Smoking/use of cocaine
Clinical presentation
- Vaginal bleeding
- Abdominal and low back pain
- Frequent contractions
- Uterine tenderness
- Hypotension, tachycardia, pallor
- Concealed hemorrhage: abdominal rigidity,
increase in fundal height
Management
- Cesarian section
- Blood transfusion
- IV fluids
- O2 inhalation

Nursing consideration
- Relieve pressure on the cord
- Elevation of the presenting part
- Oxygen at 8 – 10 LPM via face mask
- Cesarian section
Prolapsed Cord
Protusion of the umbilical
cord into the vagina

Risk factors
- Ruptured membranes
- Small fetus
- Breech presentation
- Transverse lie
- Excessive amniotic fluid
Clinical presentation
- Visible cord at the vaginal opening
- Palpable cork on vaginal examination
- Fetal bradycardia

Management
- Relieve pressure on the cord
- Elevation of the presenting part
- Oxygen at 8-10 LPM via face mask
- Cesarian section
Nursing considerations
- knee-chest or Trendelenberg position
- Monitor fetal heart tones
- Avoid palpatation or handling of the cork
- Prepare client for surgery
- Allay client’s anxiety
Uterine Rupture

Tear in the uterine wall

Most serious
complication of labor
Risk factors
1.Previous cesarian
section
2.Mulitiparity
3.Intense uterine
contractions
Clinical presentation

1.Complete rupture 2. Incomplete rupture

- sudden, severe - Abdominal pain with
abdominal pain contractions
- Abdominal rigidity - Slight vaginal
- Cessation of bleeding
contractions - Failure of cervical
- Absence of FHR dilatation
- Shock - Absence of FHR
Management
- Surgery (c section, hysterotomy, hysteretomy)
- Blood trasfusion as needed

Nursing consideration
- Monitor maternal vital signs and FHR
- Watch out for signs and symptoms of shock
- Prepare client for surgery
- Provide emtional support for the client
Labor – coordinated sequence of
uterine contractions resulting in
cervical effacement and dilation
followed by expulsion of the
products conception

Effacement – shortening and

thinning of the cervix

Lightening – descent of the fetus

into the pelvic inlet 2 weeks
prior to onset of labor
Lie – relationship of the long
axis of the fetus to the long
axis of the mother

Presentation – part of the

fetus that first enters the
mother’s pelvis

Position – relationship of the

presenting part to the
maternal pelvis

Station – measurement of
the descent of the
presenting part into the
maternal pelvis
True Labor False Labor
Near term Early in pregnancy
Increasing frequency, Irregular; non
duration and intensity progressing
Pain begins in the
Discomfort in the
back, radiates to the
abdomen abdomen and groin
Progressive fetal
descent and cervical No fetal descent and
dilation cervical dilation
“bloody show” No “bloody show”
Stages of Labor
First Stage (Dilation)
1.Latent phase (0-4cm)
2.Active phase (4-8cm)
3.Transition (8-10cm)

Nursing considerations
- Monitor maternal and fetal VS
- Monitor progress of labor
- Teach breathing techniques
- Discourage pushing until cervix is dilated
Second Stage (Expulsion)
Full cervical dilation to fetal expulsion

Nursing considerations
- Perform assessment every 5 minutes
- Monitor maternal vital signs
- Monitor FHR before, during and after contractions
- Prepare for delivery
- Maintain privacy
- Catheterize if bladder is distended
APGAR Scoring
Performed at 1 and 5 Score interpretation
minutes
- 7-10: no need for
Parameters: resuscitation
- Heart rate - 3-6: requires
- Respiratory rate resuscitation
- Muscle tone - 0-2: needs
- Reflex irritability immediate critical
care
- color
Third Stage (Placental)
Placental separation and expulsion
5-10 minutes after delivery of the baby
Signs of placental separation:
- Sudden gush of blood
- Lengthening of the cord
- Change in uterine shape
Schultze’s mechanism
Duncan’s mechanism
Nursing considerations

- Assess maternal vital signs

- Assess uterine status
- Check completeness of the placenta
- Inspect perineum
- Promote bonding
Fourth Stage (Recovery)
1-4 hours after delivery
Nursing considerations
- Check vital signs
- Palpate fundus for firmness
- Monitor color and amount of lochia
- Inspect perineum; apply ice packs
Duration of Labor
Primipara Multipara

Stage 1: 12 – 13 Stage 1: 8 hours

hours Stage 2: 20 minutes
Stage 2: 1 hour Stage 3: 4 – 5
Stage 3: 3 – 4 minutes
minutes Stage 4: 1 – 2 hours
Stage 4: 1 -2 hours
Induction of Labor
Deliberate stimulation of uterine contraction prior to
labor

1.Medical
- Oxytocin (pitocin)
- Methergine
- Prostaglandin

2.Amniotomy
- Deliberate rupture of membranes
Nursing considerations
Continuous fetal monitoring
Monitor: maternal BP, PR and progress of labor
Discontinue oxytocin infussion if
1.There is fetal distress
2.Hypertonic contractions develop
3.Signs of complications are present (hemorrhage,
shock, abruptio placenta, amniotic fluid embolism)
Inform physician
Obstetric Analgesia
Goal: to relieve pain and discomfort of labor
and delivery with the least effect on fetus

Routes:
1.Inhalation (methoxyflurane, nitrous oxide)
2.IV (sodium pentothal)
3.Regional (lidocaine, tetracanine, bupivacaine
- Lumbar epidural, caudal, subarachnoid
Nursing considerations
Monitor maternal/fetal vital signs
Monitor progress of labor
Check for allergies
Record drug used, time, amount, route, site,
client site
Empty patient’s bladder
Position client appropriatel
Dystocia
Difficult or prolonged labor

Problem in any of the following

1.Passenger
2.Passage way
3.Powers
4.Placenta
5.Psychological response of the mother
Signs of fetal distress
Slowing down of the fetal heart rate
Meconium-stained amniotic fluid

Nursing intervention
Monitor FHR
Place patient on left side
Prepare for emergency delivery
Provide emotional support
Electronic Fetal
Monitoring
Purpose: evaluate fetal condition and
tolerance of labor

external/internal

Heart rate
Pattern of Fetal Heart Rate Deceleration

1.Early deceleration

2.Late deceleration

3.Variable deceleration
Early deceleration

Deceleration begins early in contraction

Fall in heart rate stays within the normal range
Heart rate returns to baseline
Due to compression of fetal head against the
cervix
Not a dangerous pattern
No intervention needed
Late Deceleration

Deceleration start late in contraction

Fall in heart rate > 20 bpm
Heart rate does not return to baseline
Due to uteroplacental insufficiency
Dangerous pattern
Change maternal position, administer O2,
discontinue oxytocin, prepare for immediate
delivery if pattern is consistent
Variable Deceleration

Onset not related to contractions

Abrupt and dramatic swings in heart rate;
rapid return to baseline
Due to compression of the umbilical cord
Not a dangerous pattern
Change maternal position, administer O2,
discontinue oxytocin infusion
If persistent, CS will be needed
Obstetrical Procedure
Episiotomy

Incision made into

the perineum to
enlarge the opening
Prevents perineal
laceration
Types:
1.Midline (median)
2.Mediolateral
Nursing considerations
- Apply ice packs for the 24 hours
- Hot sitz bath to promote healing
- Check for signs of bleeding/infection
- Instruct client about perineal hygiene
Forcep Delivery
Indication: to Nursing
shorten second stage considerations
of labor - Explain procedure
- Fetal distress - Reassure patient
- Poor maternal effort - Monitor mother and
- Medical condition fetus continuously
- Maternal fatigue - After delivery, check
- Large infant mother and fetus for
injuries
Vacuum Extraction
Used to assist delivery of the fetal head
Suction device applied to fetal head and
traction applied during contractions
Nursing considerations
- Do not keep suction device longer than 25
minutes
- Continuous fetal monitoring
- Assess infant fro cerebral trauma
Cesarian Section
Delivery of the fetus through an abdominal and
uterine incision
Indications:
- Fetal distress
- Abnormal presentation (breech, face, shoulder)
- CPD
- Placental abnormalities
- Multiple gestation
- Previous CS
- Arrest in labor
Nursing considerations
- Obtain inform consent
- Explain procedure to the mother
- Monitor mother and fetus continuously
- Prep abdomen and pubic area
- Insert IV and catheter
- Pain relief
- Encourage turning, coughing and deep breathing
- Monitor for signs of bleeding and infection
Physiologic Changes
Involution of the Uterus

Return of the uterus to its nonpregnant size

- 1 hour postpartum: fundus at the level of the
umbilicus
- Fundus decrease by 1cm per day
- Fundus no longer palpable by the 10th day
Lochia
1.Lochia rubra – red; 1-3 days
2.Lochia serosa – pinkish-brown; 4-10 days
3.Lochia alba – yelowish-white; 11-21 days

Foul smelling lochia indicates infection

Menstrual flow resumes within 8 weeks in

nonbreastfeeding mothers, within 3-4 months in
breastfeeding mothers.
Normal blood loss: 500cc (vaginal delivery); 1 L
(CS)

Increased WBC count (up to 20,000)

Fever may be present

Colostrum secreted from 1-3 days

Hemorrhoids are common

Postpartum Discomfort
Intervention
Perineal discomfort Ice packs (1st 24 hrs) warm
sitz bath (after 24hrs)
Analgesics spray
Episiotomy perineal care after voiding
Analgesics
breastfeed frequently
Breast engorgement
Ice packs between feedings
warm soaks before feedings
Encourage verbalization

Postparutum blues
Cracked nipples Air dry nipples 1-20
minutes after feeding
rotate baby’s position
after feeding
Make sure baby is
latched on the areola
Do not use soap when
cleaning the breast
Phase of Maternal
Adjustmet
1. “Taking In”
- 1-2 days post partum
- Predominance of mother’s needs (sleep and
food)
- Help with daily activities as well as child care
- Listen to the mother’s experience during labor
and delivery
- Not the best time to do teaching about care of
the neonate
2. “Taking Hold”
- 3-10 days post partum
- Mother starts assuming the care of the
neonate
- Emotional lability may be present
- Best time to teach about baby care
- Reassure the mother that she can perform
the tasks of being a mother
3. “Letting Go”

- Fifth or sixth week postpartum

- New baby is included in new lifestyle
- Focus on entire family
- Mother may be overwhelmed by demands on
her time and energy
Postpartum
Complications
Postpartum Hemorrhage

Loss of more than 500 ml of blood

Causes:
- Uterine atony
- Lacerations
- Retained placental fragments
Nursing considerations
- Monitor vitals signs
- Monitor fundus
- IV fluids
- Administer medications
- Measure I and O
- Keep client warm
Postpartum Infection

Occurs within 10 days after birth

Predisposing factors;
- Prolonged rupture of membranes
- Cesarean section
- Trauma
- Maternal anemia
- Retained placental fragments
Clinical presentation
- Fever (100.4 F or 37.8 C) for 2 consecutive
days
- Chills
- Abdominal or pelvic pain
- Foul-smelling vaginal discharge
- Dysuria
- Increased wbc count
Management
- Antibiotics
- Warm sitz bath

Nursing considerations:
- semi-Fowler’s or high Fowler’s position
- High-calorie, high protein diet
- Increase oral fluids (>3 L/day)
Mastitis

Infection of the breast

Usually bilateral
Staphylococcus aureus
Clinical presentation
- Redness and tenderness
- Fever and chills
- malaise
Breast abscess
Management
- Antibiotics
- ice
Nursing considerations
- Teach importance of hand washing
- Empty breast regularly
- Mother may continue breastfeeding
Labor
Maternal Weight Gain
- Underweight woman: 28-40 lbs
- Normal weight woman: 25-35 lbs
- Overweight woman: 15-25 lbs
- Obese woman: less than: 15 lbs
Labor
Maternal weight gain distribution
- fetus, placenta, amniotic fluid = 11 lbs
- Uterus = 2 lbs
- Increase blood volume = 4 lbs
- Breast tissue = 3 lbs
- Maternal stores = 5-10 lbs
Labor
Umbilical cord
- One large vein
- Two smaller vein
- Made of Whaton’s Jelly
- Fetal Circulation
> ductus venosus
> Ductus arteriosus
> Foramen ovale
Labor
Adequacy of the maternal environment
- Nutrition
- Hyperthermia
- Chronic disease, diabetes, thyroid, cardiac, and
circulatory
- Substance abuse
- TORCH (T=toxoplasmosis, O=other; gonorrhea,
syphilis, varicella, hep B, group B strep. HIV,
R=rubella, C=cytomegalovirus, H=herpes
Labor
Stages of Labor
- First Stage Dilating
- Second Stage – Epulsion
- Third Stage – Placental
- Fourth Stage – Post Partum
Labor
First Stage
- Beginning gots short, mild, lasting 10-15
minutes apart, mild discomfort
- Progressively got longer, stronger, lasting 60-
90 seconds, ends woth complete dilatation
- Latent=0.3cm, 3hrs primip, 2 hrs multip.
- Transition=8-10cm, loss of control, urge to
push
labor
Second Stage
- Complete dilatation of the cervix
- 50 minutes for a primip, 20 minutes for multip
- Pushing
- Crowning
- Ends with delivery of baby
Labor
Third Stage
- Begins after delivery of baby and terminates
with the birth of the placenta
- Signs of Placental Separation
- globular and firmer uterus
- rise of uterus in abdomen
- descend of umbilical cord
- sudden gush of blood
- Placental expulsion
Labor
Fouth Stage
- First hour post partum
- Restoration of physiological stability
- Assessments
• Vital signs
• Fundus checks
• Amount lochia
• Perineum
• Bladder function or distention
• Family education- handling/breastfeeding
Labor
Position changes of
the fetus
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
Labor
Fetal Presentation
- L.O.A. – Left
occipitoanterior
- L.O.T. – Left
occipitotransverse
- L.O.P. – Left
occipitoposterior
- R.O.T. – Right
occipitoanterior
- R.O.T. – Right
occipitotransverse
- R.O.P. – Right
occipitoposterior
Delivery
Fetal position-Assessment
- Five ways
1.Abdominal palpation
2.Vaginal examination
3.Combined auscultation and examination
4.Ultrasound
5.X-ray
Delivery
Abdominal Palpation
- Leopoid Maneuver
1.Palpate the upper abdomen to determine contents
of fundus
2.Locate the fetal back in relation to the right and left
sides
3.Locate the presenting part at the inlet and check for
engagement by evaluating mobility
4.Palpate just above the inguinal ligament on either
side to determine the relationship of the presenting
part to the pelvis
Delivery
Perineum
- Episiotomy
 lateral
 medbilateral
 median
Postpartum
Breastfeeding
Teaching
Safety
Family planning
siblings
Post Partum
Lochia
- Rubra
- Serosa
- Alba