Maternity Nursing Edited Royal Pentagon 6a586z

The Royal Pentagon Review Specialist, Inc.

Maternity Nursing

Human Sexuality a. Concepts 1. A person’s sexuality encomes the complex behaviors, attitudes and emotions and preferences that is related to sexual self and eroticism 2. Sex is basic and dynamic aspect of life 3. During reproductive years, the nurse performs as resource person on human sexuality 15 – 44 y.o. – age of reproductivity CBQ b. Definitions related to sexuality Gender Identity – sense of feminity and masculinity – developed @age 3 or 2 -4 y.o. Role Identity – attitudes, behaviours and attitudes that differentiate roles Sex – biologic male or female status. sometimes referred to as specific sexual behavior such as sexual intercourse Sexuality - behavior of being a girl or boy and is identity subject to a lifelong dynamic change II.

Sexual Anatomy and Physiology a. Female Reproductive System 1. External – Vulva/ Pudenda a. Mons pubis/ veneris – mountain of venus, a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as a cushion or protection to the symphysis pubis Stages of Pubic Hair Development (Tool Used: Tanner’s Scale/ Sexual Maturity Rating) Stage 1 – Pre adolescence • no pubic hair, fine body hair Stage 2 – Occurs bet. 11 – 12 y.o • sparse, long, slightly pigmented and curly that develop along labia Stage 3 – Occurs bet. 12 – 13 y.o. • hairs become darker and curlier develops along pubis symphysis Stage 4 – 13 – 14 y.o. • hair ssumes normal appearance of an adult but is not so thick and does not appear to the inner aspect of the upper thigh Stage 5 – Sexual Maturity • assumes the normal appearance of an adult, appears at the inner aspect of thigh

b. Labia Majora – large lips latin, longitudinal fold from perenium to pubis symphysis

c. Labia Minora – aka Nymphae, soft and thin longitudinal fold created between labia majora • Clitoris – “key”, pea – shaped erectile tissue composed of sensitive nerve endings; sight of sexual arousal in females • Fourchet – tapers posteriorly of the labia majora. Site for episotomy

1

- sensitive to manipulation, torn during pregnancy

d. Vestibule – almond shaped area that contains the hymen, vaginal orifice and batholene’s gland • Urinary Meatus – small opening of urethra/ opening for urination • Skene’s Gland – aka Paraurethral Gland, 2 small mucus secreting glands for lubrication • Hymen – membranous tissue that covers the vaginal orifice • Vaginal Orifice – external opening of the vagina • Bartholene’s Gland – paravaginal gland, secretes alkaline substance, neutralizes acidity of the vagina o Doderleins Bacillus – responsible for vaginal acidity o Parumculae Mystiformes – healing of a hymen e. Perenium – muscular structure in between lower vagina and anus 2. Internal a. Vagina – female organ for ovulation, ageway of menstruation, ¾ inches 8 – 10 cm long containing rugae o Rugae – permits considerable stretching withouit tearing during delivery CBQ b. Uterus – hollow muscular organ, varies in size, weight and shape, organ of menstruation Size : 1 x 2 x 3 Shape : pear shaped, pregnant - ovoid Weight : Uterine involution CBQ Non pregnant : 50 – 60 g Preganant : 1000 g 4th stage of Labor : 1000 g 2nd week after of Delivery : 500 g 3rd weeks after delivery : 300 g 5 – 6 Weeks after delivery: 50 – 60 g Three Parts of Uterus • Fundus – upper cylindrical layer • Corpus/ Body – upper triangular layer • Cervix – lower cylindrical layer Isthmus – lower uterine segment during pregnancy Muscular Composition: 3 main Muscles making possible expansion in all direction a. Endometrium  muscle layer for menses o Lines the non-pregnant uterus o Volumes the non pregnant uterus o Decidua – slouching off of endometrium during menstruation o Endometriosis  Ectopic Endometrium  Common site is ovaries  Proliferation of abnormal growth of lining of outer part  Persistent dysmenorrhea, low back pain  Dx Exam: biopsy,laparoscopy  Tx: Lupron (luprolide)  inhibits FSH & LH  Tx: Danazol (Danacrine) DOC 1. Inhibits ovulation

2

2. stop menstruation b. Myometrium o Power of labor o Smooth muscles is considered to be LIVING LIGATURE (muscles of delivery, capable of closing) of the body o Largest portion of the uterus c. Peremetrium o Protects the entire uterus c. Ovaries • 2 female sex gland • almond shape • Fxn: Ovulation,production of 2 hormones( estrogen and progesterone) d. Fallopian Tube • 2 – 3 inches long that serves as a ageway of the sperm from the uterus to the ampulla or the ageway of the mature ovum or fertilized ovum from the ampulla to the uterus • 4 significant segments o Infundibulum – most distal part, trumpet shape, has fimbrae o Ampulla – outer 3rd or 2nd half, site of fertilization, common site for ectopic preg. o Isthmus – site for sterilization, site for BTL o Interstitial – most dangerous site for ectopic pregnancy b. Male Reproductive System 1. External • Penis • The male organ of copulation and urination • Contains of a body or shaft consisting of 3 cylindrical layers and erectile tissues o 2 corpora cavernosa o 1 corpus spongiosum • At the tip is the most sensitive area comparable to clitoris = glans penis • Scrotum • Pouch hanging below the pendulous penis, with medial septum deviding into 2 sacs each containing testes • Requires 2 degrees celcius for continuous spermatogenesis • Cooling mechanism of testes 2. Internal The Process of Spermatogenesis Testes (900 coiled seminiferous tubules) ↓ epididymis (site of maturation of sperm 6 m) ↓ Vas Deferens (conduit pathway of sperm) ↓ Seminal Vesicle (secreted: fructose form of glucose, nutritative value

3

Prostaglandin: causes reverse contraction of uterus) ↓ Ejaculatory Duct (conduit of semesn) ↓ Prostate Gland (release alkaline substances) ↓ Cowpers Gland (release alkaline substance) ↓ Urethra Hypothalamus GNRH ↓ APG ↓ FSH – maturation of sperm LH – testosterone production Leydig Cells – releases testosterone Male & female Homologues Male Female Penile Glans Clitoris Penile Shaft Clitoral shaft Testes Ovaries Prostate Skene’s gland Cowper’s Glands Bartholin’s Gland Scrotum Labia Majora III.

Basic Knowledge on Genetics and Obstetrics

1. 2. 3. 4.

DNA – Deoxyribonucleic Acid – carries genetic code Chromosomes – threadlike structure of hereditary material known as the DNA Normal amount of ejaculated sperm – 3 – 5 cc/ 1 teaspoon Ovum is capable of being fertilized within 24 – 36 hours after ovulation. 5. Sperm 48 – 72 days viability 6. Reproductive cells divide by the process of MEIOSIS (haploid number) • Spermatogenesis – process of maturation of sperm • Oogenesis – process of maturation of ovum o 30 weeks AOG – 6 million immature ovum o @ birth – 1 million immature oocytes o @ puberty – 300 – 400 immature oocytes o @ 13 y/o – 300 – 400 mature oocytes o @ 23 y/o – 180 – 280 mature ovum o @ 33 y/o – 60 – 160 mature ovum o @ 36 y/o – 24 – 124 mature ovum o @46 y/o – 4 mature ovum • Gametogenesis – process of formation of two haploid into diploid 7. Age of reproductivity – 15 – 44 y/o childbearing age – 20 – 35 y/o High risk  <18 & >35 y.o. With Risk  18 – 20; 30 – 35

4

8.

Menstruation • Menstrual Cycle – beginning of menstruation to the beginning of the next menstruation • Average menstrual cycle – 28 days • Average menstrual period – 5 days • Normal blood loss – 50 cc/ ¼ cup accompanied by FIBRINOLYSIS – prevents clot formation • Related terminologies o Menarche – 1st menstruation o Dysmenorrhea – painful menstruation o Metrorrhagia – bleeding in between menstruation o Menorrhagia – Excessive bleeding during menstruation o Amenorrhea – absence of menstruation o Menopause – cessation of menstruation (Average Age- 51 y.o.)  Tofu – has isoflavone – estrogen of plant that mimics the estrogen with a woman 9. Functions of Estrogen and Progestin • ESTROGEN – hormone of woman o Primary function  Responsible for the development of secondary characteristics in females  inhibit production of FSH o Other function  Hypertrophy of the myometrium  Spinnbarkeit and Ferning Pattern (Billings Method)  Ductile structure of the breast  Osteoblastic bone activity (causes increased in height)  Early closure of the epiphysis of the bone  Sodium retention  Increased sexual desire  Responsible for vaginal lubrication • PROGESTERONE – Hormone of the mother o Primary function – prepares the endometrium for implantation making it thick and tortous o Secondary Function – inhibit uterine contractibility o Others  Inhibit LH (hormone of ovulation) production  ↓ GI motility  ↑ Permeability of kidneys to lactose and dextrose causing + 1 sugar in urine  Mammary gland development  ↑ BBT  Mood swings 10. Menstrual Cycle 4 phases of menstrual cycle 1. Proliferative 2. Secretory 3. Ischemic

5

4. Menses

1. On the initial phase of menstruation, the estrogen level is ↓, this level stimulates the hypothalamus to release GnRH/ FSHRF

2. GnRH/ FSHRF stimulates the anterior pituitary gland to release FSH •

FSH Function o Stimulate ovaries to release estrogen o Facilitate the growth of primary follicle to become GRAAFIAN FOLLICE  structure that secretes large amount of estrogen that contain mature ovum 3. Proliferative Phase (↑estrogen) Follicular Phase – responsible for the variation and irregularity of mense Postmenstrual Period – after menstruation Preovulatory Phase – happen before menstruation 4. 13th day of menstruation, estrogen level is PEAK while progesterone is ↓, these stimulates the hypothalamus to release GnRH/ LHRF 5. GnRH/ LHRF stimulates the Anterior Pituitary Gland to release LH • Functions of LH o Stimulates the release of progesterone o Hormone for ovulation 6. 14th day estrogen level is ↑ while progesterone level is ↑ • S/S o Rupture of the graafian follicle - OVULATION o Mittelschsmerz – slight abdominal pain lower right quadrant th 7. 15 day, after ovulation day, graafian follicle starts to degenerate, estrogen level ↓, progesterone ↑, causing degeneration of the graafian follicle becoming yellowinsh known as CORPUS LUTEUM – secretes large amount of progesterone 8. Secretory Phase Lutheal Phase (↑progesterone) Postovulatory phase Premenstrual Phase 9. 24th day – Corpus Albicans (whitish) corpus luteum degenerates and becomes white 10. 28th day – if no sperm united the ovum, the uterine begins to slough off to have the next menstruation Note: • if there is no fertilization, corpus luteum continues functioning • Ovarian Cycle – from primary follicle – corpus albicans • Stages: o 1 – 5 days – menses o 6 – 14 – proliferative o 15 – 26 – secretory o 27 – 28 – ischemic 11. Stages of Human Sexual Response Initial Response: VASOCONGESTION – constriction of blood vessels MYOTONIA – increased muscle tension • Excitement Phase • ↑ muscle tension, moderate VS

6

•

•

•

•

erotic stimuli causing ↑ sexual tension, may last from minutes to hours Plateu Phase • ↑ and sustained tension near orgasm • may last 30 sec – 30 minutes Orgasm • Involuntary release of sexual tension accompanied by physiologic and psychologic release, • immeasurable peak of experience 2 – 3 seconds Resolution • Return to normal state • VS return to normal

REFRACTORY PERIOD – only period present in male, wherein he cannot restimulated for about 10 – 15 minutes IV.

I. II. III. IV.

I.

Wonders of Fertilization a. Fertilization 1. Phonones – song of sperm 2. Capacitation – ability of sperm to release proteolytic enzyme and penetrate the ovum b. Stages of Fetal Growth and Development 1. Pre Embryonic Stage Zygote  fertilized ovum (3 – 4 days travel, 4 days floating)> from fertilization Morula  mulberry-liked ball containing 16 – 50 cells Blastocyst  enlarging cell forming a cavity that later becomes the embryo covered by thropoblast which later becomes the placenta and membrane Implantation  7 – 10 days after fertilization • Thropoblast – covering of blastocyst that become placenta • S/Sx of Implantation  Slight pain, Slight Vaginal Spotting • 3 Processes o Apposition o Adhesion o Invasion 2. Embryonic Stage Zygote – fertilization to 14 days Embryo – 15th – 2 mos/ 8 weeks Fetus – 2 mos to birth c. Decidua – thickened endometrium, latin word for “falling off” 1. Basalis – located directly under the fetus where placenta developed 2. Caspularis – encapsulates the fetus 3. Vera – remaining portion of and endometrium d. Chorionic Villi – 10 – 11 weeks 1. Chorionic Villi Sampling (CVS) – removal of tissue from the fetal postion of the developing placenta • For genetic screening • Fetal limb defects, missing digits of toes e. Cytothrophoblast – outer layer, LANGHAN’S LAYER, protect the fetus against syphilis (24 weeks/ 6 months) f. Synsitiotrophoblast – syncitial layer – responsible for hormone production 1. Amnion – inner most layer 2. Chorion Umbilical cord (Funis) – whitish gray (50 – 60 cm)

7

• •

II.

Short  abruptio placenta, uterine inversion Long  cord prolapse, cord coil • 3 vessels (AVA) – Artery Vein Artery • Wharton’s Jelly – protects the umbilical cord Amniotic fluid  bag of water  clear color, musty/mousy odor • With crystallized forming pattern, slightly alkaline • 500- 1000 cc Normal o Oligohydramnios – kidney malformation o Hydramnios – GIT , TEF/ TEA • Functions o Cushion the fetus against sudden blow or trauma o Maintains temperature o Facilitate muscuskeletal development o Prevents cord compression o Helps in development process

Diagnostic Test for Amniotic Fluid  Amniocentesis • Purpose: obtain sample of amniotic fluid by inserting a needle hrough the abdomen into the amniotic sac • Fluid is tested for: • Genetic screening • Determination of fetal maturity primarily by evaluating factors indicative of lung maturity • Done with empty bladder • Complication > Most common side effect : INFECTION > Late : pre term labor > Early : spontaneous abortion • Indication for Amniocentesis: > Early in Pregnancy Advance Maternal Age > Later in Pregnancy Diabetic Mothers • ↑ - down syndrome • ↓ - neural tube defect, spina befida • L/S ratio : 2:1 (Lecitin/ Spingomyelin) • Definitive test = Phosphatiglycerol: PG +  best Answer • Greenish – Meconium Stains (Fetal Distress) • Yellowish – jaundice, hyperbilirubinemia • Cloudy – Infection • Most Important Consideration  Needle insertion site • Amnioscopy – direct examination through intact fetal membrane via ultrasound • Fern Test – a test determining if bag of water has rupture or not • Nitrazine Paper Test – differentiate amniotic fluid and urine Blue geen  + rupture of bag of H2O

2. Chorion – outermost layer a. Placenta – AKA Secundines  chorionic Villi and basalis • • •

Pancake in latin 500 grams in weight 15 – 28 cotyledons

8

• •

15 – 20 cm in diameter and 2 – 3 cm in depth Functions o Respiratory  02 – CO2 exchange via simple diffusion o GIT  glucose transport via facilitated diffusion o Excretory  via 2 arteries, carries unoxygenated blood then detoxify by maternal liver o Circulatory  fetoplacental circulation by SELECTIVE OSMOSIS o Endocrine  HCG – primary maintain corpus luteum/ secondary basis of pregnancy test  Human Placental Lactogen – aka Somatomammothrophin • Responsible for the development of mammary gland • Diabetogenic Effect – insulin antagonist  Relaxin – softening of maternal ts and bones o Serves as protective barrier against some microorganism  Can : HIV CMV Rubella  PINOCYTOSIS – transport of virus

Pregnancy – 266 – 288 days/ 37 – 42 weeks FETAL STAGE: Fetal Growth and Development First Trimester : Period of organogenesis, most critical period First Month FHT, CNS Develops, GIT and Respi Tract remains as single tube Differentiation of Primary Germ Layer • Endoderm o Thyroid – responsible for basal metabolism o Thymus – immunity o Liver o GIT o Linings of Upper GI Tract • Mesoderm o Heart o Musculoskeletal o Reproductive Organ o Kidney • Ectoderm o Brain o CNS o Skin o 5 senses o Hair, nails o Anus o Mouth Second Month • Life span of corpus luteum ends • All vital organs are formed

9

• Placenta is developed • Sex organ is developed • Meconium is present Third Month • Placenta is complete • Kidneys are functional • Fetus begins to swallow amniotic fluid • Buds of milk appear • Sex is distinguishable • FHT audible via dopples @ 10 – 12 weeks Terratogens – any drug or irradiation, the exposure to which may cause damage to the fetus • DRUGS o Streptomycin – anti – TB – (quinine) damage to the 8th cranial nerve  poor learning and deafness/ ototoxic o Tetracycline – stoning the tooth enamel, inhibits long bone growth o Vitamin K – hemolysis, destruction of RBC, jaundice, hyperbilirubenemia o Iodides – enlargement of thyroid and goiter o Thalidomides – anti-emetics  Amelia or Pocomelia  absence of distal part of extremities o Steroids – cleft lip or palate and even abortion o Lithium – congenital maformation • ALCOHOL – LBW, fetal alcohol syndrome ( characterized by microcephaly) • SMOKING – LBW • CAFFEINE – LBW • COCCAINE – LBW, abruptio placenta • TORCH – group of infections that can cross the placenta or ascend through the birth canal and adversely effect fetal growth o Toxoplasmosis – cat lovers o Others - Hepa AB, HIV, Syphillis o Rubella – CHD,  Rubella Titer – N @ 1:10 or ↓ = immunity to rubella = notify doctor  Rubella vaccine after delivery for 3 mos. No pregnancy for 3 mos. o Cytomegalo virus o Herpes Simplex virus Second Trimester : continuous growth and development (focus  lengh of fetus) Fourth Month • Lanugo begins to appear • Buds of permanent teeth appear • FHT audible via Fetuscope @ 18 – 20 weeks Fifth Month • Quickening : 1st fetal movement Primi: 18 – 20, Nulli - 16 - 18 • Lanugo covers the body • FHT audible via stethoscope or w/out instrument • Actively swallow amniotic fluid • Fetus : 19 – 25 cm Sixth Month • Skin is red and wrinkled • Vernix caseosa covers the skin

10

• Eyelids open • Exhibits startle reflex 3rd Trimester : period of most rapid growth and development Focus: weight Seventh Month • Surfactant development • Male: the testes begins to descent into the scrotal sac • Female : clitoris is prominent and labia majora are small doesn’t cover the minora Eight Month • Active moro reflex • Lanugo begins to disappear • Sub q fats deposits, steady weight gain, nails to fingers Ninth Month • Lanugos and vernix caseosa is evident in body fold • Birth position assumed • Amniotic fluid somewhat decrease • Sole of the foot has few creases Tenth Month • Bone ossification in the fetal skull • Vernix caseosa is evident in body PHYSIOLOGIC ADAPTATION TO PREGNANCY Systemic Changes 1. Cardiovascular System • ↑ blood volume 30 – 50% • 1500 cc; additional 500 cc for multiple pregnancy • ↑ plasma volume • ↑ cardiac workload – easy fatigability/ slight ventricular hypertrophy • Epistaxis due to hyperemia of nasal membrane • Palpitation due to SNS stimulation • Physiologic Anemia/ pseudoanemia in pregnacy o Normal Value Hct : 32 – 42% Hgb: 10.5 – 14 g/dl o Criteria 1st & 3rd Trimester : Hct > 33% Hgb > 11 g/dl 2nd Trimester : Hct > 32% Hgb > 10.5 g/dl o Pathologic Anemia  Iron Defficiency Anemia is the most common hematologic disorder. It affects 20% of pregnant women  Assesment reveals: • Pallor • Slowed capillary refill = Normal = 2 – 3 sec • Concave fingernails (late sign of progressive anemia) – clubbing = chronic tissue hypoxia • constipation  Nursing care • Nutritional instruction o Source of iron  Kangkong

11

•



• • Alert • • •

•

• •

•

•

 Liver = best source due to FERRIDIN Content  Red and lean meat  Green Leafy Vegetables Parenteral Iron (Imferon) o Z tract IM o incorrect causes hematoma o best given 1 hour before meals (causes GI irritation) o Maybe given 2 hours after meal (results to poor absorption)  Given with orange juice to ↑ absorption Oral Iron Supplements (ferrous sulfate 0.3 g 3 x a day) Monitor for hemorrhage Iron from red meat is better absorbed iron from other sources Iron is better absorbed when taken with foods high in Vitamin C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs

Edema o Impeded venous return due to the gravid uterus o Nursing Intervention  Elevate legs above the hips level Varicosities o Wear stockings o Elevate legs Vulvar Varicosities o D/t pressure of gravid uterus o Side –lying with pillow under the hips o Modified knee – chest position Thrombophlebitis o Presence of thrombus in inflamed blood vessels o + Homan’s Sign – pain on the calf upon dorsiflexion o Medical Management  Anticoagulant/ HEPARIN • Does not cross the placental barrier • Monitor APTT • Antidote: PROTAMINE SULFATE • No aspirin Milk Leg/ Plagmasia Alba Dolens o Shiny white legs due to stretching of skin & hyperfibrinogenemia o Nursing intervention  Check dorsalis pedis pulse (compare both)  Never massage  Assess for Homan’s sign only once

2. Respiratory System • Shortness of Breath d/t gravid uterus • Nursing intervention: Side-lying – lateral expansion of the lungs

12

3. Gastrointestinal System • Nausea and vomiting • Morning Sickness o Due to ↑ HCG levels o Crackers 30 min before arising o AM – Carb diet 30 mins o PM – small frequent meal • Constipation o Due to PROGESTERONE = ↑ fluid reabsorption due to ↓ GIT motility o Nursing intervention • ↑ Fluid • ↑ Fiber • Exercise • Flatulence o Due to increased progesterone o Avoid gas forming foods • Heartburn (pyrosis) o Reflux of stomach content into esophagus o Nursing Intervention • Small frequent meals • Sips of milk • Avoid fatty and spicy foods • Proper body mechanics o Waist Above – Acid o Waist Below – Base • Hemorrhoids o Due to gravid uterus o Hot sitz bath for comfort • Ptyalism o ↑ salivation o Mouthwashes to relieve 4. Urinary System • Normal = + 1 sugar due to Progesterone via BENEDICT’S TEST • First Trimester - Frequency • Second Trimester - normal • Third Trimester - Frequency 5. Muscoloskeletal • Calcium sources o Milk - ↑ Ca ↑ P – 1 pint/ day or 3 – 4 servings/ day o Cheese, Yogurt, Head of Fish, Sardines, Anchovies, Brocolli • Lordosis o Pride of Pregnacy • Waddling Gait o Awkward gait while walking due to relaxin o Prone to accidental falls  Wear low healed shoes • Leg Cramps o Ca – P Imbalance during pregnancy o Lumbo-sacral nerves by pressure of gravid uterus during labor

13

o o o

Over sex Dorsiflex the foot affected 3-4 servings/ 4 cups/day sa milk, sardines, dilis

A. Local Chnages • •

•

Vagina o Chadwick’s Sign – bluish discoloration o Leukorrhea – whitish gray, moderate in amount, mousy odor Cervix o Goodel’s Sign – change in consistency of uterus o Operculum – mucus plug to seal bacteria/ progesterone Uterus o Hegar’s Sign – change in consistency Vagina Cervix Uterus

Chadwick’s Goodel’s Hegar’s

Problems related to the changes of Vaginal Environment a. Vaginitis - AVOCADO • Trichomonas Vaginalis o Flagellated protoxzoan, Loves alakaline environment • Signs and Symptoms o Greenish, cream, colored, frothy, irritably itchy, foul smelling vaginal discharge o Vaginal edema • Management o Drug of choice: METRONIDAZOLE (Flagyl)  Antiprotozoan  Carcinogenic  Not given in 1st trimester • vaginal douche as substitue o 1 qt Water = 1 tbsp white vinegar o Treat partner as well to prevent reinfection o No alcohol – due to antabuse effect b. Moniliasis - CHEESE • Candida Albicans • Transvaginal transfer in fetus – Oral Trush • Signs and Symptoms o White Cheeselike patches that adheres to the walls of the vagina • Management o Antifungals  Mycostatin  Contrimazole – Canisten  Gentian Violet 1. Abdominal Changes • Striae Gravidarum o Due to destruction of the subcutaneous tissue by the enlarge uterus 2. Skin Changes

14

• •

Melasma/ Chloasma o White light brown pigmentation related to ↑ melanocytes Linea Nigra o Brown pinkish line from symphysis pubis to umbilicus

3. Breast Changes • Due to hormonal changes • Change in color and size of nipple and areola • Precolostrum – 6 weeks • Colustrum – 3rd trimester • Supine with pillow under the back 4. Ovaries – rest period, no ovulation 5. Signs and Symptoms of Pregnancy Presumptive Probable S/sx felt and observed by the Signs observed by mother but does not confirm the of the the diagnosis of pregnancy health care team First Breast changes Goodel’s sign trimester Urinary changes Chadwick’s sign Fatigue Hegar’s sign Amenorrhea Elevated BBT Morning sickness Positive HCG Enlarge uterus Second Chloasma Ballotement Trimester Linea Nigra Enlarge Abdomen Increase Skin Pigmentation Braxton Hicks Striae gravidarum Contraction Quickening

Positive Undeniable signs confirmed by the use of instrument Ultrasound Evidence

etal Heart Tone etal movement etal outline etal parts palpable

CBQ Cancer of the Breast  quadrant B Mamography 35 and above  1/ year Ballotement  bouncing of the fetus  may be present in uterine myoma Transvaginal Ultrasound – empty bladder Abdoiminal ulrasound – full bladder Placenta Grading System • Grade 0 – immature • Grade 1 – slightly mature • Grade 2 – moderately mature • Grade 3 – fully mature • What is deposited?  calcium VI. Psychological Adaptation to Pregnancy – Reva Rubin First Trimester • No tangible s/sx • Feeling of surprise • Ambivalence • Denial of pregnancy  maladaptation • Developmental Task: Accept biological facts of pregnancy

15

•

Health Teaching: Body changes of pregnancy and Nutrition

Second Trimester • Tangible s/sx • Mother identifies fetus as separate entity due to quickening • Fantasy • Developmental Task: Accept growing fetus as a baby to nurture • Health Teaching: Growth and development of fetus Third Trimester • Mother has personally identifies with the appearance of the baby • Developmental Task: Prepare child birth and parenting the child • Health Teaching: responsible parenthood, prepare baby’s layette, Lamaze Class • Address Mother’s fear  let she hear the FHT

VII. Pre – Natal Visit Basic Consideration 1. Frequency of Visit • 1 – 7th mos.  once a month • 8 – 9th mos.  twice per month • 10th month  every week 2. Personal Data • Home Based Mother’s Record/ HBMR  determines high risk pregnancy • Pseudocyesis  false pregnancy  appearance of presumptive & probable signs • Comade Syndrome  psycosomatic disorder, father experience what the mother goes through 3. Diagnosis of Pregnancy • Urine Exam HCG  40 – 100th day; peak 60 – 70th day • ELISA  beta subunits of HCG is detected as early as 7 – 10th day • RIA  beta subunits of HCG is detected as early as 8th day • Home Pregnancy Kit 4. Baseline Data • Roll – Over Test  test of pre-eclampsia by the use of BP • Weight monitoring Normal Weight Gain st 1 Trimester = 1.5 – 3 lbs  1 lb/ mo 2nd Trimester = 10 – 12 lbs  4 lbs/mo 3rd Trimester = 10 – 12 lbs  4 lbs/mo Minimum allowable weight gain  20 – 25 lbs Optimal weight gain  25 – 35 lbs 5. Obstetrical Data

a. Gravida  no. of pregnancy b. Para  no. of viable pregnancy 16

Viability  the ability of the fetus to live outside the uterus at the earliest possible gestational age 1 abortion 1 pregnancy 3rd mos.

1 39TH Week, 1 miscarriage, 1 still birth, 1 2nd mo. preg G4P2 G4 T1 P1 A1 L1

G2P0 G2 T0 P0 A1 L0 c. Important Estimates 1. Nagele’s Rule • Use to determine expected date of delivery • Jan – Mar  +9 months +7 days • Apr – Dec  -3 months +7 days + 1 year 2. McDonald’s Rule • Determines age of gestation in weeks • Fundic Height x 7/8 = AOG in weeks 3. Bartholomew’s Rule • Determines age of gestations o 3 mos – above pubis symphysis o 5 mos – level of umbilicus o 9 mos – below xiphoid process o 10 mos – level of 8th mos 4. Haases Rule • Determines the length of fetus in cm. • 1st half  square each month • 2nd half  month x 5 d. Tetanus Immunization • TT1 – anytime or early during pregnancy • TT2 – 1 month after TT1  3 years protection • TT3 – 6 months after TT2 – 5 years of protection • TT4 – 1 year after TT3  10 years of protection • TT5 – 1 year after TT4  lifetime protection 5. Physical Examinations a. Danger Signs of Pregnancy Chills & Fever Cerebral Disturbances Abdominal Pain  epigastric pain  auro of impending convulsion Boardlike Abdomen  Abruptio placenta Blurred Vission  pre eclampsia Bleeding  abortion/ ectopic pregnancy – 1st trimester  H Mole/ Incompetent Cervix – 2nd trimester  Placental Anomalies – 3rd Trimester BP ↑ Swelling Scotoma – spots in the eye Sudden gush of fluid – PROM – premature rupture of membrane

17

6. Pelvic Examination      

 

 

Pelvic examination or IE – empty bladder, precaution 1st visit – Chadwicks, Goodle’s sign, etc. Position : dorsal recumbent, lithotomy Pap smear – done 1st visit Cytological exam – determine presence of cancer cells. Result : o Class I – normal o Class II A – cytology without evidence of malignancy B – suggestive of inflammation o Class III – cytology suggestive of malignancy o Class IV – cytology suggestive og malignancy o Class V – conclusive for malignancy Most common cancer report organ : cervical cancer Most common site for pap smear – external OS of cervix (squamocolumnar tissue) Common site of cervical cancer. maternal – speculum (open) Stages of cervical cancer o 0 – carcinoma in situ o 1 – Ca strictly confined to cervix o 2 – from cervix extends to the vagina o 3 – pelvic metastasis o 4 – affectation to bladder & rectum

7. Leopolds Maneuver  Purpose: Done to determine the attitude, fetal presentation, lie, presenting part, degree of descent an estimate of the size, and no. of fetuses  Procedure 1. 1st maneuver o place patient in supine position with knees slightly flexed. Put towel under head and right hip. With both hands palpate uppe4r abdomen and fundus. Assess size, shape, movement and firmness of the part o determine the presenting parts: 2. 2nd maneuver o with both hands moving down, identify the back of the fetus where the ball of the stethoscope is placed to determine FHT. o PR of mother : uterine soufflé – MHR o fundic soufflé – FHR 3. 3rd maneuver o using the right hand, grasp the symphysis pubis part using the thumb and fingers. o Assess whether the presenting part is engaged in the pelvis. o Alert! If the head is engaged it will not be movable 4. 4th maneuver o the examiner changes the position by facing the patient’s feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. o When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head 8is flexed and vertex presenting.  Attitude – relationship of fetus to one another.  Full Flexion – when the chin touches the chest 8. Assessment of Fetal Well-being

18

a. Daily fetal Movement Counting (DFMC)  Done starting 27th week  Consideration  fetal sleep wake pattern  maternal food intake  drug-nicotine use  environmental stimuli  maternal dose  Cardiff count to 10 method – one method currently available o begin at the same time each day (usually in the morning after breakfast ) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs) o expected findings – 10 movements in 1hrs or less o warning signs – 10-12 movements in 1hr or less  more than 1hr to reach 10 movements  less than 10 movements in 12hrs  longer time to reach 10 FMs than on previous days.  movements are becoming weaker, less vigorous  movement alarm signal <3 FMs in 12hrs o warning signs should be reported to healthcare provider immediately; often require further testing. Eg. Non stress test (NST), biophysical profile (BPP) b. Nonstress Test o to determine the response of the fetal heart rate to the stress to activity. o Indications – pregnancies at risk for o placental insufficiency o Postmaturity • pregnancy induced hypertension (PIH), diabetes • warning signs noted during DFMC • maternal history of smoking, inadequate nutrition o Procedure : • Done within 30mins wherein the mother is in semifowlers position; external monitor is applied to document fetal activity; mother activates the “mark button” on the electronic monitor when she feels fetal movement. Attach external noninvasive fetal monitors • tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) • ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected • monitor until at least 2 FMs are detected in 20mins. o if no FM after 40mins provide women with a light snack or gently stimulate fetus through abdomen o If no FM after 1hr further testing may be indicated, such as a CST o Result : • Noncreative Nonstress Not Good • Reactive Response is Real Good o Interpretation of results • Reactive result – real good  baseline FHR between traction beteen 120 and 160 beats per min.  at least two accelerations of the FHR of at least 15 beats per min., lasting at least 15secs in a 10 to 20 min period as a result of FM

19

good variability – normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (↓ FHR) and sympathetic (↑ FHR) nervous system; noted as an uneven line on the rhythm strip  result indicates a healthy fetus with an intact nervous system Nonreactive result – not good  stated criteria for a reative result are not met  could be indicative of a compromised fetus requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST) 

o

9. Health Teachings o do nutritional assessment o daily food intake o determine habit o if ↓ folic acid – lead to spina bifida/open neural tube defect o HIGH RISK MOTHERS • pregnant teenagers – poor compliance to health regimen • extremes in wt – underwt – eg. Elite models overwt – eg. DM/HPN • low social economic status. Refer to OSWD • vegetarian mothers because ↓ intake of vit B12 (Cyanocobalamin) – formation of folic acid (cell DNA & RNA formation) • types :  strict vegetarian – prone to develop anemia  lacto vegetarian – milk  lacto-ovo vegetarian – milk & egg a. Recommended Nutrient Requirement that Increases During Pregnancy Nutrients Requirements Food sources Calories Essential to supply energy for 300 calories/day above the Caloric ↑ should reflect prepregnancy daily requirement • foods of high nutrient value • metabolic rate to maintain ideal body weight such as protein, complex • Utilization of nutrients and meet energy requirement of carbohydrates (whole grains, • Protein sparing so it can activity level vegetables, fruits) be used for : • begin ↑ in 2nd Trimester • variety of foods representing o growth of fetus • use wt-gain pattern as an food sources for the nutrients o development of indication of adequacy of required during pregnancy structures requires calories intake • no more than 30% fat for pregnancy • failure to meet caloric including placenta, requirements can lead to Na – 3gms/day – eat in amniotic fluid, tissue ketosis as fat & protein are moderation growth used for energy, ketosis has CHON x 4K Cal been associated with fetal CHO x 4K Cal damage. Fats x 9K Cal Non pregnant: 2200 calories Pregnant: 2500 calories 2200+500 @ lactation=2700 cal Protein Essential for • fetal tissue growth

60mg/day or an ↑ of 10% above daily requirements for age group

Protein ↑ should reflect • Lean meat, poultry, fish

20

• • •

maternal tissue growth including uterus and breasts. Development of essential pregnancy structures Formation of RBC and plasma proteins

Inadequate protein intake has been associated with onset of pregnancy induced hypertension (PIH) Calcium-Phosphorous Essential for • Growth and development of fetal skeleton and tooth buds • Maintenance of mineralization of maternal bones and teeth • Current research is demonstrating an association between adequate calcium intake and the prevention of pregnancy induced hypertension Iron Essential for • Expansion of blood volume & RBC formation • Establishment of fetal iron stores for first few months of life

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

Calcium ↑ of • 1200mg/day representing an ↑ of 50% above pre pregnancy daily requirement • 1600mg/day is recommended for adolescent • 10mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous

Non Pregnat:15mg/day Pregnant : 30mg/day - representing a doubling of the prepregnant daily requirement • Begin supplementation at 30mg/day in second trimester, since diet alone is unable to meet pregnancy requirement • 60 – 120mg/day along with copper and zinc supplementation for women who have low Hgb values prior to pregnancy or who have iron deficiency anemia • 70mg/day of vitamin C which enhances iron absortion o Inadequate iron intake results in maternal effects anemia, depletion of iron stores, ↓ energy and appetite,

• Eggs, cheese, milk • Dried beans, lentils, nuts • Whole grains Vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids

Calcium ↑ should reflect • Dairy products, milk, yogurt, ice cream, cheese, egg yolk • Whole grain, tofu • Green leafy vegetables • Canned salmon & sardines with bones • Ca fortified foods such as orange juice • Vitamin D sources fortified milk, margarine, egg yolk, butter, liver, seafood

Iron ↑ should reflect • liver, red meat, fish, poultry, eggs • enriched, whole grain cereals & breads • dark green leafy vegetables, legumes • nuts, dries fruits • vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, tomatoes, green peppers, broccoli or cabbage, potatoes • iron form food sources is more readily absorbed when served with foods high in vit C

21

•

Zinc Essential for • the formation of enzymes • maybe be important in the prevention of congenital malformation of the fetus Folic acids, folacin, folate Essential for • Formation of RBC & prevention of anemia • DNA synthesis & cell formation; may play a role in the prevention of neural tube defects (spina bifida), abortion, abruption placenta Additional requirements Minerals • Iodine • Magnesium • selenium

Vitamins E Thiamine Riboflavin Pyridoxine (B6) B12 Niacin

cardiac stress especially during labor & birth o fetal effects ↓ availability of oxygen thereby affecting fetal growth iron deficiency anemia is the most common nutritional disorder of pregnancy

15 g/day representing an ↑ of 3mg/day over prepregnant daily requirement

Zinc ↑ should reflect • liver, meats • shell fish • grains, legumes, nuts

400mcg/day representing an ↑ of more than 2x the daily prepregnant requirement

↑ should reflect • Liver. Kidney, lean beek, veal • Dark, green leafy vegetables, broccoli, asparagus, artichokes, legumes • Whole grains, preanuts

300mcg/day supplement for women with low folate levels or dietary deficiency

175mcg/day 320mg/day 65mcg/day

↑ requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy

10mg/day 1.5mg/day 1.6mg/day 2.2mg/day 2.2mcg/day 17mg/day

b. Sexual Activity • Principles of sex in Pregnancy o Should be done in moderation o Should be done in a private place o That the mother should be placed in a comfortable position o It must be avoided 6 weeks prior to EDD o Avoid blowing of air during cunnilingus • Contraindication in sex: o vaginal spotting – 1st tri o incompetent cervix – 2nd tri o placenta previa, abruption placenta – 3rd tri o pre-term labor R: prostaglandin – oxytocin – contraction

22

•

o PROM – infection Changes in sexual appetite during pregnancy: o 1st tri - ↓ o 2nd tri - ↑ o 3rd tri - ↓

c. Exercise • strengthen muscle to be used during the delivery process • Walking – best form of exercise • Squatting – strengthen perineum & ↑circulation to the perineum (raise the buttocks before head to prevent postural hypotension) • Tailor sitting – same purpose with squatting • Kegel exercise – strengthen pubococcygeal muscle • Abdominal exercise – muscle of the abdomen ( done as if blowing a candle) • Shoulder circling exercise – strengthen muscle of the chest • Pelvic rocking exercise or pelvic tilt – relieve low back pain & maintain good posture (arching back for 3 sec) • Principles of exercise o must be done in moderation o must be individualized d. Childbirth Preparation • Overall goal: To prepare patents physically & psychologically while promoting wellness behavior that can be used by parents & family thus, helping them achieved a satisfying & enjoying childbirth experiences.

•

•

•

Psychological o Bradley Method – Dr. Robert Bradley – discoverer  advocated active participation of husband during labor & delivery to serve as coach, based on “imitation of nature”  Features: • darkened room • quiet & calm environment • relaxation technique • close eyes o Grantly Dick Read Method  fear can lead to tension while tension can lead to pain. (break cycle by removing the fear-by abdominal breathing exercises & relaxation technique) Psychosexual o Kitzinger Method – Dr. Shiella Kitzinger  pregnancy, labor & birth & the care of the newborn is an important turning point in a woman’s life cycle. “flowing with contractions rather than struggle with contractions” Psychoprophylaxis o Lamaze – Dr. Ferdinand Lamaze  Prevention of pain thru mind & requires discipline, conditioning & concentration with the husband’s help.  Features: • conscious relaxation

23

• •

•

cleansing breathe – inhaling thru nose & exhaling thru mouth effleurage – gentle circular massage • over abdomen to relieve pain • imaging Different methods of delivery o birthing chain – semi-fowlers – mother o bathing bed – dorsal recumbent o squatting – position relieve on back pain & maintain good posture o Leboyer’s method  features : • darkly lighted room • quiet & calm environment • room temp. • soft music o Birth under water

IX. INTRAPARTAL NOTES A. itting the laboring Mother • Personal data • Baseline data • Obstetrical data • Physical exams • Pelvic exams B. Basic knowledge in intrapartum • Theories of the Onset of Labor o Uterine Stretch Theory – any hollow organ once stretched to its maximum potential will always contract & expel its content o Oxytocin Theory – released by PPG, contraction effect o Prostaglandin Theory – stimulation by Arachidonic acid, causes contraction of uterus o Aging Placenta – 42wks (lifespan) by 36wks placenta begins to degenerate causes contraction o Progesterone deprivation theory - ↓ level of progesterone will facilitate contraction of the uterus • The 4 Ps of Labor o enger – fetus  fetal head • is the largest presenting part • ¼ of its length • Bones – 6 bones (sphenoid, temporal, ethmoid) Frontal, occipital & 2 parietal bones • Sutures/intermembranous spaces – allows molding • Molding – the overlapping of the sutures of the skull to permit age of the head to the pelvis o Sagittal bones – connect to parietal bones o Cororontal bones – connect to parietal & frontal bones o Lambdoidal bones – connect to parietal & occipital bones • Fontanels o 6 fontanels only 2 palpable  anterior fontanel/Bregma • diamond in shape

24

• • •

3cm x 4cm size close 12-18 mos post delivery ↑ 5cm – hydrocephalus  posterior fontanel/lambda • triangular in shape • 1 x 1cm size • close 2-3mos post delivery • Measurements of fetal head : o transverse diameter  Bi-parietal - largest transverse diameter- 9.25cm  Bi-temporal - 8cm  Bi-mastoid - smallest transverse diameter - 7cm o AP diameter  Suboccipitobregmatic – complete flexion  Occipitofrontal – partial flexion - 12cm  Occipitotemporal – largest AP diameter; hyperextended (13.5cm)  Submentobrgmatic - face presentation; poor flexio o ageway – vagina & pelvis  Pelvis • 4 main pelvic types o gynecoid – round, wide, deeper, most suitable for pregnancy o android – heart shape “male pelvis” – anterior pointed post part – shallow o Anthropoid – oval “ape-like pelvis“ AP wider transverse narrow o Platypelloid – flat transverse oval AP narrow transverse – wider – c/s for delivery • Problem : o mother who encounter accident o ↓ 4’9” o ↓ 18y/o – R: pelvis not achieve its full pelvic growth  Bones of pelvis • 4bones o 2 hips (2 innominate bones)  3parts of 2 innominate bones • Ileum – lateral/side of hips o Iliac crest – flaring superior border that forms prominence of hips; common site for bone marrow aspiration • Ischium – inferior portion o Ischial tuberosities of the area where we o Sit; basis in getting external measurement of pelvis • Pubis – anterior portion o Symphysis pubis – junction in between o sacrum – posterior portion  Sacral prominence – basis internal measurement of pelvis

25

o 1 coccyx - 4 small bones that compresses during vaginal • •

delivery universal precaution in measurement of pelvis is to empty bladder first Important Measurements o Diagonal Conjugate  measure between Sacral promontory & inferior margin of the symphysis pubis  Measurement 11.5-12.5 cm  Basis in getting the true conjugate. o True Conjugate/Conjugate Vera  Measure between the anterior surface of the sacral promontory & superior margin of the symphysis pubis.  Measurement: 11.0 cm  Diagonal conjugate: 1.5 cm = true conjugate. o Obstetrical Conjugate  smallest AP diameter of the pelvis measuring 10cm or more. o Tuberoischii Diameter  transverse diameter of the pelvic outlet.  Approx by a fist- 8cm & above.

Power  the forces acting to expel the fetus & placenta • involuntary contractions • voluntary bearing down efforts • characteristics: wave like • timing: frequency, duration, intensity  myometrium – power of labor o Psyche/person  psychological stress exist when the mother is fighting the labor experience. • cultural interpretation preparation • past experience • system Pre-eminent signs of labor o Preeminent Signs  lightening • settling of the presenting part into the pelvis brim (shooting pain radiating to the legs, urinary frequency) • primi- early 2 weeks prior to EDD • engagement – settling of presenting part into pelvic inlet (not signs of labor)  Braxton Hicks Contractions – painless irregular contractions  Increase Activity of the Mother – Nesting • Instinct (mgt: save energy) • epinephrine production (hormone that ↑ the activity of the mother)  Ripening of the cervix –butter softness  Decrease in weight – 1.5-3 lbs.  Bloody show • pinkish vaginal discharge (blood + leucorrhea + operculum = pink in color) o

•

26

Rupture of membranes • check FHT • IE check for cord prolapse • after several hrs – check temp. o Premature Rupture of Membranes (PROM)  contraction drop in intensity even though very painful  contraction drop in frequency  uterus tense &/or contracting between contractions  abdominal palpitations  Nursing Care: • ister analgesics (morphine) • attempt manual rotation for ROP or LOP • bear down with contractions • adequate hydration • sedation as ordered • cesarean delivery may be required, especially if fetal distress is noted o Cord Prolapse  a complication when the umbilical cord falls or is washed through the cervix into the vagina.  Danger Signs: • PROM • Presenting part has not yet engaged • Fetal distress • Protruding cord from vagina – cerebral palsy – ↑ 5 mins., irreversible brain damage mgt: CS  Nursing Care • Positioning – knee chest or trendelenberg, place wet sterile gauze R: to make it slippery • Observe for fetal distress • Provide emotional • Prepare for cesarean section 

•

•

•

Difference Between True and False Contraction True False • No in intensity • • Pain confined in the abdomen • • Pain is relieved by walking • • No cervical changes •

There is an in intensity Pain begins @ the lower back to abdomen Pain is intensified by walking Cervical effacement (thinning of the cervix, measured thru %) & dilatation (widening of the cervix, measurement thru cm) *best/major sign of true labor

Duration of Labor o Primipara – 14 hrs but not more than 120 hrs o Multipara – 8 hrs but not more than 14 hrs Nursing Interventions in Each Stage of Labor o First Stage: onset of contractions to full dilatation & effacement of the cervix o stage of effacement & dilatation

27

Latent Phase: • Assessment: o Dilatations 0-3 cm o Frequency 5-10 mins o Duration 20-40 mins o Intensity mild o Mother is excited, apprehensive but can communicate • Nursing Care: o Encourage walking : shortens 1st stage of labor o Encourage to void q 2-3 hrs : full bladder inhibits uterine contraction o breathing (chest breathing technique)  Active Phase: • Assessment: o Dilatations 4-8 cm o Frequency q 3-5 mins lasting for 30-60 secs o Duration 30-60 secs o Intensity moderate • Nursing Care: o M – edications – have meds ready o A – ssessment include: v/s, cervical dilatation & effacement, fetal monitor, etc o D – ry lips – oral care (ointment), dry linens o Breathing – abdominal breathing  Transitional Phase: • Assessment: o Dilatations 8-10cm o Frequency q 2-3 mins contractions o Duration 45-90 sec o Intensity strong o Mood of mother suddenly change accompanied by hyperesthesia (hypersensitivity of mother to touch) of the skin • Management o sacral pressure, cold compress • Nursing care: o T – tires o I – inform of progress (to relieve emotional ) o R – restless her breathing technique o E – encourage & praise o D – discomfort Pelvic Exams  Effacement & Dilatation • Station – relationship of the presenting part to the ischial spine o 5 - -1 = the presenting part is above the ischial spine o Engagement 10 = the presenting part is in line with the ischial spine o (-) fetus is floating o (+) below the ischial spine • Presentation o the relationship of the long axis of the fetus to the long axis of the mother. 

o

28

o

spine relationship of the spine of the mother & the spine of the fetus

o

Two Types  Longitudinal Lie (Parallel)/ Vertical • Cephalic – when the fetus is completely flexed o Vertex o Face o Brow o Chin • Breech o Complete breech – thigh rest on abdomen while legs rest on thigh o Incomplete breech  Frank – thigh resting on abdomen while legs extend to the head  Footling  Kneeling  Transverse Lie (Perpendicular)/Horizontal lie • Position – relationship of the fetal presenting part to specific quadrant of the mother’s pelvis. o ROA/LOA  left occipito anterior  most common & favorable position o ROT/LOT – left occipito transverse o ROP/LOP – left occipito posterior

o L/R- side of maternal pelvis o Middle – presenting part o ROP/ROT – most common malposition o ROP/LOP – most painful mgt: pelvis squatting

o Breech – sacro place the stethoscope above the umbilicus o Chin – mentum o Shoulder – acromnio dorso Monitoring the contractions & fetal heart tone • spread the finger lightly over the fundus to monitor the contraction • Increment/Cresendro - beginning of contraction until it increases • Apex/Acne – height of contraction • Decrement/Decresendro – from height of contraction until it decreases • Duration – beginning of contraction to the end of the same contraction • Interval – from end of contraction to the beginning of the next contraction 



29

• • • •

• •

Frequency – from the beginning of 1 contraction to the beginning of next contraction Intensity – strength of contraction if contract – blood vessel constricts; the fetus will get the oxygen on the placenta reserve which is capable of giving oxygen to the fetus up to 1min. Duration of placenta to the fetus should not exceed 1min. Significance During active phase, if ↑ to 1min should notify the AMD ↑ BP; ↓ FHT : best time to get BO & FHT just after a contraction

NURSING CONSIDERATION DURING THE FIRST STAGE OF LABOR  Bath is necessary  Monitor VS especially BP o Same BP = rest o Elevated = notify the physician  NPO o Prevent aspiration  chemical pneuminitis  Enema (per hospital policy) o Purpose  Cleanse the bowel  Prevent infection o 12 – 18 inches normal length of tube o 18 inches optimal length o Lateral sims position o If there is contraction  clump the tube o If there is resistance  slowly remove o Before and after istration: check FHT (120 – 160) and contractions  Encourage mother to void  Perennial preparation (rule of 7)  Rest on left side lying position o Prevent supine vena cava syndrome or supine hypotension  If membrane doesn’t rupture  amniotomy  FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen  For Pain o Systemic analgesic  DEMEROL (Meperidine HCl) • Narcotic and antispasmonic • Don’t give during latent phase • Given @ 6-8 cm dilated • WOF : Respiratory depression • Narcan (Naloxone, nalorfan, nalline) o Antidote for toxicity o Injected on the baby  Epidural Anesthesia • WOF : Hypotension • Prehydrate the client to prevent hypotension • In case of Hypotension o Elevate leg o Fast Drip IV

30

SECOND STAGE OF LABOR (FETAL STAGE)  Complete dilatation and effacement to birth  Crowning occurs  PRIMI – transfer to DR @ 10 cm dilatation  MULTI – transfer to DR @ 7 – 8 cm dilatation  Position in lithotomy both legs at the same time  BULGING OF PERENIUM  surest sign of delivery initiation  PANT & BLOW Breathing, fetal pushing should be done on an open glottis  Respiratory alkalosis o Due to incorrect breathing o Hyperventilation o S/sx  ↑ RR  Lightheadedness  Tingling sensation  Carpopedal spasm  Circumoral numbness Episiotomy  Prevent laceration  Widen the vaginal canal  Shortens the 2nd stage of labor  2 types o MEDIAN  Less bleeding  Less pain  Easy repair  Possible urethroanal fistula  major disadvantage o MEDIOLATERAL  More bleeding  More pain  Hard to repair and slow healing  Ironing the Perenium  prevent laceration Mechanism of Labor (ED FIRE ERE)  Engagement  Descent  Flexion  Internal Rotation  Extension  External Rotation  Expulsion PELVIS  3 Parts o Inlet – AP diameter narrow, transverse wider o Cavity – between inner and outer o Outlet – AP diameter wider, transverse narrow  LINEA TERMINALES

31

Nursing Care  MODIFIED RIGEN’S MANEUVER o Done by ing the perenium with a towel during delivery o Facilitates complete flexion o Avoids laceration  First intervention: the head and suction secretion  Do not milk the cord, wait for pulsation to stop before cutting o Milking may cause too much blood going to the baby that may cause cardiac overload  When there is still birth, let the mother see the baby to accept the finality of death THIRD STAGE OF LABOR (PLACENTAL STAGE)  3 – 10 minutes after child birth  1st sign  Fundus rises  CALKIN’S SIGN  Signs of Placental Separation o Fundus becomes globular and rises  calkin’s sign o Lengthening of the cord o Sudden gush of blood  BRANT – ANDREW’S MANEUVER o slowly pulling the cord and wind at the clamp o rapidly  may cause uterine inversion Types Placental Delivery  SHULTZ (Shiny) o From center to the edges o Presenting fetal side  DUNCAN (Dirty) o Form edges to center o Presenting the maternal side Nursing Considerations during placental delivery  Check placental completeness o Should be 500 g  Check Fundus – Massage if Boggy  BP Check  Methergine, methylergonovine mallate (IM)  Oxytocin (IV) if methergine is not present  Check perenium for lacerations  Assist in episioraphy  Vaginoplasty/ Vaginal Landscape – Virgin again FOURT STAGE OF LABOR (Recovery Stage)  First 1 – 2 hours after delivery of placenta  Maternal observation – body system stabilize o 1st hour – q15 min 2nd hour - q 30 min  Placement of fundus o In between umbilicus and pubis symphysis o Check bladder, assist in voiding, May lead to uterine atony  hemorrhage  Lochia  Perineum o Check REEDA

32

R edness E dema E cchymosis D ischarge A pproximation Fully saturated – 30 – 40 cc Weighing – 1 cc = 1 gram Common Board Question

    

o o

Nursing Consideration during Recovery  Flat on bed to prevent dizziness  If with Chills  give blanket due to dehydration  Give nourishment (progression of meal) o Clear liquids – gatorade, ginger juice, gelatins o Full liquid – milk, ice cream o Soft diet o Regular diet  Check VS/ Pain  Pychic State  Bonding – interaction between mother and newborn o Strict – 24 hours with mother o Partial – morning with mother, night nursery COMPLICATIONS OF LABOR Dystocia  Difficult labor related to mechanical factor  Primary cause is Uterine Inertia Uterine Inertia  Sluggishness of contraction  Types o Primary/ Hypertonic  Intense contraction resulting to ineffective pushing  Management : Sedation o Secondary/ Hypotonic  Slow, irregular contraction resulting to ineffective pushing  Management : Oxytocin Augmentation Prolonged Labor  > 20 H for primi  > 14 H for multi  proper pushing should be encourage if inappropriate: o may cause fetal distress o caput succedaneum o cephalhematoma o maternal exhaustion  monitor contractions and FHT Precipitate Labor  labor less than 3 hours  causes excessive laceration leading to profuse bleeding  hypovolemic shock  s/sx of hypovolemic shock HYPO TACHY TACHY

33

o HYPOtension o TACHYpnea o TACHYcardia o o

Cold clammy skin Management  Modified trendelenburg  Fast Drip IV

Inversion of Uterus  Situation in which uterus is turn inside out due to: o Short cord o Hurrying of placental delivery o Ineffective fundal push  Cause profuse bleeding  hypovolemic  Hysterectomy Uterine Rupture  Rupture of uterus  Caused by o Previous classical CS o Very large baby o Improper use of oxytocin  S/sx o Sudden pain o Profuse bleeding  Prepare fore TAHBSO Physiologic Retraction Ring  boundary between upper and lower uterine segment Bandl’sPathologic Ring  suprapubic depression sign of uterine rupture Amniotic Fluid/ Placental Embolism  Anaphylactic syndrome of pregnancy  Situation in which placental fragment and amniotic fluid enters maternal circulation  S/Sx o Dyspnea o Chest Pain o Frothy Sputum o End Stage – DIC  Prepare for R, Suction and emergency etc Trial Labor  Fetal head measurement = measurement of pelvis  6 hours labor allowance given to mother  monitor FHT and contractions Preterm Labor  labor after 20 weeks and before 37 weeks  Triad signs o Premature conditions every 10 minuets o Effacement of 60 – 80% o Dilatation of 2 – 3 cm  Home Management

34

CBR Avoid Sex Empty bladder Drink 3 – 4 Glasses of H2O  Full bladder inhibit contraction  Hospital Management o If Cervix Close (Criteria: cervix is closed if it is 2 – 3 cm dilated only)  2 – 3 cm dilated, pregnancy can be saved  Tocolytic Therapy • Yutupar (Ritodine HCl) o Side effect maternal BP < 90/60 o Check Impt. Presence of crackles • Brethine (terbutaline) Bricanyl o DOC o Side effect: sustained tachycardia o Antidote: propanolol/ inderal • Mg SO4 o If cervix is dilated ( > 4cm)  Give steroid dexamethasone • Promote surfactant maturation • Immediately cut the cord after delivery to prevent jaundice/ hyperbilirubinemia o o o o

POSTPARTAL PERIOD Puerperium – 5th stage of labor, 1st 6 weeks post partum Characterize by involution Involution - return to the normal stage of reproductive organ after pregnancy Return to Normal Healing Physiologic Changes Systemic Changes  Cardiovascular System o ↑plasma volume o sudden ↓ in blood volume o elevated WBC’s up to 30, 000 mm3 o hyperfibrinogenemia o orthostatic hypertension can be possible o early ambulation prevents thrombos formation  steps in ambulation • Flat • Semifowlers • Fowlers with dangling • Walk with assist  Genital Tract o Fundus  goes down 1 finger breadth a day  10th day – non palpable behind the symphysis pubis  Subinvolution • delayed healing of uterus containing quarters or clots of blood

35

•

• o

o

may lead to puerperal sepsis Management : D&C

After Pains  After birth pains  Multiparous breastfeeding – most common to develop  Position = prone  Cold compress  Mefenamic acid Lochia  Components • Blood • Deciduas • WBC • Microorg  3 types • Rubra – 1 – 3 days, musty, moderate amount • Serosa – 4 – 10th day, pink or brown • Alba – 10 – 21th day, crème white, ↓ amount

 Urinary Tract o Urinary Frequency – due to urinary retention with overflow o Dysuria  Damage to trigone of the bladder  Urine collection for culture and sensitivity  Stimulate navel to urinate  Palpate bladder  Running water listening  Pull pubic hair - stimulate cremasteric reflex  Colon o Constipation  Due to NPO  Bearing down may cause pain  Perenium o Pain relieved by sim’s position o Cold compress 1st 24 hours if there is pain at episioraphy followed by warm EMOTIONAL 1. Taking phase • 1st 3 days • dependent phase • ive, can’t make decision • tells about childbirth experience • focus on: Hygiene 2. Taking Hold • 4 – 7th day • dependent to independent phase • active, decides actively • focus: care of newborn

36

• health teaching : Family planning 3. Letting Go • Interdependent phase • Redefines goals, new roles as parents • May extend till the child grows Post Partum Blues • 4th – 5th days • overwhelming feeling of depression, inability of sleep and lack of appetite • 50 – 80% incidence rate • cause by sudden hormaonal change – progesterone suddenly decreases • allow crying: therapeutic • may lead to postpartum psychosis/ depression Postpartal Complications Hemorrhage  bleeding within 24 hours postpartum Early Pospartal Hemorrhage 1. Uterine Atony  boggy fundus  profuse bleeding  interventions o massage the uterus o cold compress o modified trendelenburg o fast drip IV o breastfeeding – to release oxytocin 2. Laceration  well contracted uterus with profuse bleeding  assess perenium for laceration  degrees of laceration o 1st degree – vaginal skin and mucus membrane o 2nd degree – 1st degree + muscles o 3rd degree – 2nd degree + external sphincter of rectum o 4th degree – 3rd degree + mucus membrane of rectum 3. Hematoma  bluish discoloration of subQ tissues of vagina or perenium  candidates o delivery of very large babies o pudendal block o excessive manipulation due to excessive IE  intervention o cold compress 10 – 20 min then allow 30 minutes rest period for 24 h 4. DIC – disseminated intravascular coagulation  Consumption of pregnancy (otherterm)

37

Failure to coagulate Bleeding in the eyes, ears, nose Oozing blood Seen in cases with o Abruptio placenta o Still birth / IUFD  Management o Blood transfusion of cryoprecipitate or fresh frozen plasma o hysterectomy    

Late Postpartum Hemorrhage Retained placental fragments  manual extraction of fragments is done  uterine massage  D&C except for cases of o Placenta Acreta – umusual attachment of the placenta to the myometrium o Placenta Increta – deeper attachment of placemat to the myometrium o Placenta Percreta – invasion of placenta to the perimetrium  Candidates of these disorders are • Grand multiparous • Post CS  All these requires hysterectomy Infection  Sources o Endogenous – from normal flora of the body o Exogenous – from the health care team  Most common – Anaerobic Streptococci  Management o ive care o ↑ Fluid intake o TSB if there is fever/ cold compress + paracetamol may also be given o Analgesics  Given on time to achieve maximum effect o Culture and sensitivity Perenial Infection  Same s/ sx with infection  2 – 3 stitches are dislodges  with purulent drainage  Tx – resuturing Endometritis  Inflammation of the endometrium  Gen s/sx of infection + abdominal tenderness  Management o High fowler’s – facilitates drainage & localize infection o ister oxytocin FAMILY PLANNING METHOD

38

Guiding Principles 1. determine your own beliefs first 2. never advise a permanent method of family planning 3. informed concent 4. the method is an individual decision Natural Method – accepted by the church Billing’s/ Cervical Mucus/ Spinnbarkeit • clear watery & stretchable • 13th day – longest due to estrogen Basal Body Temp – in the morning before arising/ 13th – 14th day due to peak of progesterone LAM – Lactational Amenorrhea Method  prolactin – inhibits ovulation  breastfeeding – 4 – 6 months no menstrual cycle  bottle fed – 2 – 3 months Sympthothermal – combination of Billings and BBT – most effective method Social Methods Coitus Interuptus  withdrawal  least effective method Coitus Reservatus  sex w/o ejaculation Coitus interfemora  between femor Calendar Method  14 days before menstrual cycle – ovulation day (regular)  - 4, + 4 days – unsafe period Origoknause Formula ( irregular menstrual cycle)  get the longest and shortest cycle  subtract 18 to shortest  11 to the longest  the difference is the unsafe period PILLS  combined oral contraceptives preventovulation by inhibiting the anterior pituitary gland roduction of FSH and LH which are essential for he maturation and rupture of a follicle.  Estrogen inhibit FSH which is responsible in the mturation of ovum. Progesterone inhibit LH which is responsible for ovulation.  contains estrogen that inhibits FSH and progesterone that inhibit LH  99.9% effective  21 day feel on the 5th day of mense start taking  28 day – 1st day of mense  if forgotten, take 2 tablets the following day  adverse effect : breakthrough bleeding  if mother wants to get pregnant o wait 3 monts o another 3 months if unsuucessful before consulting gyne  contraindications o chain smoking

39

o Hypertension o DM o Extreme obesity o Thrombophlebitis  Side effects (ressembles Hypertension)/ Immediate Discontinuation o Abdominal paon o Chest pain o Headache o Eye problem o Severe leg cramp  Alerts on oral contraceptives : o In case a Mother who is taking an oral contraceptive for almost a long time and plans to have a baby, she would wait for at least 3mos before attempting to conceive to provide time for estrogen and progesterone levels to return to normal. If after 6months the mother did not get pregnant, consult AMD. o If a new oral contraceptive is prescribed, the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses. o Discontinue oral contraceptive if there is signs of severe headache as this are an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage. o If forget to drink pill for 1 day, take 2 pills the next day. If forget to drink pills for 2days, stop the pill and wait for the next mens.  Adverse reaction : breakthrough bleeding DMPA – Depoprovera  Contains progesterone  Depomedroxy progesterone Acetate  IM q 3 months – never massage the site  may decrease effectiveness NORPLANT  6 match stick like capsules/ rod  contain progesterone  sub Q planted  good for 5 years Mechanical Device IUD  prevent implantation  alters mobility of sperm and ovum  99.7% effective  best inserted after delivery and during menstruation  Common complication – EXCESSIVE MENSTRUAL FLOW  Common problem – EXPULSION OF THE DEVICE  No protection against STD  Side effects include o Uterine infection o Uterine perforation o Ectopic pregnacy  Major indication for the use is PARITY  HT: monthly check up and regular pap smear

40

CONDOM  Made up of latex  Put in erected penis or lubricated vagina  Prevents sperm to enter the uterus  FEMALE CONDOM – higher protection than that of male DIAPRAGHM  Dome shaped rubberied material inserted at the cervix to prevent sperm getting inside the uterus  Reusable  HT : Proper hygiene o Check for holes o Must be refitted in case of weight gain of 15 lbs - - board question o Kept in place for about 6-8 Hours – Board question  Contraindicated to o Frequent UTI CERVICAL CAP  More durable than the diaphram  Could stay on place for more than 24 hours  No need to apply spermicides  Contraindicated to – abnormal papsmear CHEMICAL SPERMICIDES  FOAMS – most effective  Jellies  Creams  These may cause toxic shock syndrome SURGICAL METHOD  Bilateral tubal Ligation o @ isthmus o 20% probability of reversal  Vasectomy o Vas deferens is cut o More than 30 x or 0 sperm count or 2 x negative sperm count before it could be consider safe sex

HIGH RISK PREGNANCY HEMORRHAGIC DISORDERS General management  CBR  Avoid sex  Prepare ultrasound – determine the sac integrity  Assess bleeding and approximation

41

 Assess hypovolemia  Save discharge for histopathology o Determine whether the product of labor has been expelled First Trimester Bleeding Abortion – termination of labor before age of viability  SPONTANEOUS o AKA miscarriage o Causes 1. Chromosomal aberrations due to advanced maternal age 2. Blighted ovum 3. germ plasm defect o Natures way of expelling defective babies o Classifications : 1. Threatened • pregnancy is jeopardized by bleeding and cramping but the cervix is closed and can be saved. 2. Inevitable • moderate bleeding, cramping, tissue protrudes from the cervix and the cervix is open. o Types : 1. Complete • all products of conception are expelled. • Mgt : emotional 2. Incomplete • placenta and membranes retained. • Mgt : D&C  HABITUAL o 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. o Management (suture of cervix) 1. McDonald procedure • Temporary circlage • Side effect – infection • May have NSD 2. Shirodkar • CS delivery  MISSED o fetus dies; product of conception remain in uterus 4 weeks or longer o signs of pregnancy cease 1. (-) pregnancy test 2. Dark brown 3. Scanty bleeding o Mgt : induction of labor/ vacuum extraction  INDUCED o Therapeutic abortion  principle of 2 fold effect 1. Done when mother has class 4 heart disease Ectopic Pregnancy • occurs when gestation is location outside the uterine cavity • Common site : Ampulla or Tubal

42

•

Dangerous site: Interstitial Unruptured • Missed period • Abdominal pain within 3- 5wks of missed period (maybe generalized of one sided) • Scant, dark brown vaginal bleeding • Vague discomfort

• •

• •

•

•

Ruptured sudden, sharp severe unilateral pain, knife like shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm & phrenic nerve) (+) Cullen’s sign – bluish tinged umbilicus syncope/fainting

Nursing Care : o vital signs o ister IV fluids o monitor for vaginal bleeding o monitor I&O o prepare for culdocentesis to determine o hemoperitoneum Mgt : non-surgical Methotrexate

SECOND TRIMESTER BLEEDING Hydatidiform Mole / “bunch of grapes” • Gestational Trophoblastic Disease – progressive degeneration of Chorionic Villi • gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed from the swelling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46xx. It grows and enlarges the uterus very rapidly. • Cause : Unknown • Assessment : o Early signs  vesicles ed thru the vagina  Hyperemesis gravidarum due to ↑ HCG  Fundal height  Vaginal bleeding (scant or profuse) o Early in pregnancy  high levels of HCG  Pre ecclampsia at about 12wks  Vesicles look like a “snowstorm” on sonogram  Anemia  Abdominal cramping o Serious late complications  Hyperthyroidism  Pulmonary embolus • Nursing care : o prepare for D&C o do not give oxytocin drugs due to proneness to embolism o Health Teaching:  return for pelvic exams as scheduled for one year to monitor HCG and assess for enlarged uterus and rising titer could be indicative of choriocarcinoma

43

 

Avoid pregnancy for at least one year Methotrexate therapy

Incompetent Cervix Management: • McDonald procedure o temporary circlage of incompetent cervix. o Delivery : NSVD o SE: infection o Health teaching  observe for signs of infection  signs of labor • Shhirodkar procedure o permanent procedure. o Delivery : caesarian section required. THIRD TRIMESTER BLEEDING “PLACENTAL ANOMALIES” Placenta Previa • it occurs when the placenta is improperly implanted in the lower uterine segment, sometime covering the cervical os. • Assessment o Outstanding sign : frank, bright red, painless bleeding o enlargement (usually has not occurred) o fetal distress o abnormal presentation • Nursing care : o Initial mgt : NPO candidate for CS o Bedrest o prepare to induce labor if cervix is ripe o ister IV o No IE, No Sex, No enema – complication : Sudden fetal blood loss o prepare Mother for double set –up –DR is converted to OR Abruptio Placenta • it is the premature separation of the placenta from the implantation site. • It usually occurs after the twentieth week of pregnancy • Cause: o Cocaine o Severe PIH o Accident • Assessment: o Outstanding sign : dark red & painful bleeding o concealed hemorrhage (retroplacental) o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction o rigid boardlike abdomen o severe abdominal pain o dropping coagulation factor (a potential for DIC) o sx : bleeding to any part of the body. Mgt : for hysterectomy • General Nursing care : o infuse IV, prepare to ister blood

44

o o o o o o

• type and crossmatch monitor FHR insert Foley catheter measure bllod loss; count pads report s/s of DIC monitor v/s for shock strict I&O

Placental Succenturiata – 1 or 2 lobes connected to the placenta by a blood vessel Placenta Bipartita – placenta divided into 2 lobes HYPERTENSIVE DISORDER Pregnancy Induced Hypertension o HPN after 24wks resolved 6wks postpartum which cause pregnancy. o Types : o Gestational HPN  HPN without edema & proteinuria.  Mgt : monitor BP o Pre-eclampsia – triad o sx : HPN with edema, proteinuria or albuminuria (HEP/A) which cause is unknown or idiopathic but multifactoral  primis d/t 1st exposure to chorionic villi  multiple pregnancies due to ↑ exposure to chorionic villi  Mothers of low socio-economic status due to ↓ protein intake  Teenagers d/t low compliance to protein intake o HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count Transitional Hypertension – HPN between 20-24wks Chronic or Pre-existing Hypertension o HPN before the 20th wk not resolved 6wks postpartum o 3 types of pre-eclampsia o Sign of pre-eclampsia : o > 30mmHg systolic o > 15mmHg diastolic o Roll over test  10-15min side lying  Then supine  Then take BP o mild pre-ecclampsia  140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : ↑ wt, inability to wear wedding ring due to developing edema  Signs present • cerebral & visual disturbances, epigastric pain to liver edema and oliguria usually indicates an impending convulsion • Before convulsion : if you see sign of epigastric pain, 1º mgt is to place tongue depressor and put the side rales up • During convulsion : observe the Mother for safety • After convulsion – turn to side to facilitate drainage o Severe pre-ecclampsia

45

160/110, +3 or +4, proteinuria, visual disturbances  Nursing care  P – promote bedrest  Prevent convulsions by nursing measures • to ↑ O2 demand & facilitate Na excretion • Management: quiet & calm environment, minimal handling, avoid moving the bed • Heat Acetic Acid – determine protein in the urine • Prepare the following at bedside o tongue depressor, Suction machine & O2 tank  E – ensure high protein intake (1g/kg/day) • Na in moderation  A – antihypertensive drug with hydraluzine  C – CNS depressant with Mg Sulfate for anti-convulsion • Mgt : evaluate for hypermagnesiumenimia  E – evaluate physical parameters for Magnesium Sulfate toxicity : • B – BP ↓ • U – Urine output ↓ • R – RR ↓ • P – Patellar reflex is absent • Antidote : Ca gluconate Eclampsia – with seizure  ↑ BUN – sign of glumerular damage



o

46

Diabetes Mellitus o cause by absent & lack of Insulin o Action of Insulin is to facilitate transfer of glucose into the cell o Dx test : 50gm 1hr Glucose Tolerance Test o ↑ 130 – hyperglycemia

47

o ↓ 70 – hypoglycemia o 80-120 – euglycemia o if > 130mg/dl, the Mother needs to undergo a 3hr GTT o Maternal Effects : o hypoglycemia during the 1st trimester development of the brain sinisipsip ng fetus yung glucose ng nanay. o Hyperglycemia during the 2nd & 3rd trimester  HPL effect Mgt : give insulin. OHA are teratogenic.  1st trimester - ↓ insulin, 2nd trimester - ↑ insulin, post partum – drop suddenly  Frequent infections eg. Moniliasis  Polyhydramnios  Dystocia o Fetal Effects : o hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd trimester thru facilitated diffusion o Macrosomia/LGA .4000gms o IUGR due to prolonged DM o Preterm birth promote still birth o Newborn Effects : o Hyperinsulinism and Hypoglycemia  40mg/dl  Normal : 45-55mg/dl  Borderline : 40mg/dl  Sx : ↑ pitched shrill cry, tremors, jitteriness  Dx test : heel stick test to check glucose levels o Hypocalcemia  < 7mg/dl  Calcemic tetany  Tx : Ca gluconate Heart Disease o Classification : o I – no limitation o II – Slight limitation, ordinary activity causes fatigue  good prognosis can deliver vaginally  Mgt : sleep of 10hrs/day, rest 30mins after meals o III – moderate limitation, less than ordinary activity causes discomfort  poor prognosis. Good for vaginal delivery  Mgt : early hospitalization by 7-8mos o IV – marked limitation of physical activity for even at rest there is fatigue  poor prognosis. Good for vaginal delivery only with regional anesthesia.  Low forceps delivery when unable to push & to shorten the stage of labor  Mgt : • therapeutic abortion, high semi- fowlers position, left side lying, no valsalva maneuver - may trigger cardiac arrest, heparin therapy required, antibiotic therapy for prevention of sub acute bacterial endocarditis INTRAPARTAL COMPLICATIONS

48

Cesarean Delivery • Indications a. multiple gestation b. diabetes c. active herpes II d. severe toxemia e. placental previa f. abruption placenta g. prolapse of the cord h. cephalo pelvic disproportion and primary indication i. breech presentation j. transverse lie • procedure : o classical – vertical incision o low segment – “bikini”, for aesthetic purposes. Can have vaginal birth after c/s Genotype – genetic make-up Phenotype – Physical appearance Karyotype – pictorial analysis of individual chromosome for detecting chromosomal abnormalities Autosomal Dominant • huntington’s chorea • retinoblastoma • achondroplasia • polydactyl Autosomal Recessive • sickle cell • Cystic fibrosis • Celiac • PKU • Galactosemia X- Linked Recessive • Hemophilia • Duchenne’s muscular dystrophy • Color blindness X – Linked Dominant • Rickette’s

49