maternal & child nursing care [autosaved]


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Health: Maternal and child nursing.

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maternal & child nursing care [autosaved]

  2. 2. HUMAN SEXUALITY 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 changeGILBERT T. SALACUP RN,MSN
  4. 4. DEVELOPMENT(TOOLUSED: 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 assumes 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 thighGILBERT T. SALACUP RN,MSN
  5. 5. Parumculae Mystiformes – healing of a hymenGILBERT T. SALACUP RN,MSN
  6. 6. 7 OPENING OF EXTERNAL GENITALIA S – kenes Duct (2) U – rethra B – artholins Duct (2) V – agina A - nusGILBERT T. SALACUP RN,MSN
  7. 7. Uterus – hollow muscular organ, varies in size, weight and shape, organ of menstruationGILBERT T. SALACUP RN,MSN
  8. 8. Uterus Size : 1T x 2W x 3L Shape : NP – P P–O Mu - G Weight : Non pregnant : NP - 50 – 60 g Preganant : P- 1000 g 4th stage of Labor: 4THS - 1000 g 2nd week after of Delivery: 2 500 g 3rd weeks after delivery: 3 300 g 5 – 6 Weeks after delivery: 5-6 50 – 60 gGILBERT T. SALACUP RN,MSN
  9. 9. LAYERS OF THE UTERUS Endometrium - Muscle layer for menses Myometrium - Power of labor Peremetrium - Protects the entire uterus Three Parts of UterusFundus – upper cylindrical layerCorpus/ Body – upper triangular layerCervix – lower cylindrical layerIsthmus – lower uterine segment During pregnancy GILBERT T. SALACUP RN,MSN
  10. 10. POSITION DEVIATION OF UTERUS• Anteversion – a condition in which the fundus is tipped forward• Retroversion – a condition in which the fundus is tipped back• Anteflexion – a condition in which the body of the uterus is bent sharply forward at the junction with the cervix• Retroflexion – a condition in which the body is bent sharply back GILBERT T. Friday, May 25, 2012 SALACUP RN,MSN leMaN 10
  12. 12. OVARIES N – o Peritoneal Covering A – lmond Shape T – hree 3-4Lcm2-3W1-3T I –nfundibulo Pelvic Ligament E – strogen & Progesteron Oogenesis – process of maturation of ovum GILBERT T. SALACUP RN,MSN 30 weeks AOG – 6 million immature ovum @ birth – 1 million immature oocytes @ puberty – 300 – 400 immature oocytes @ 13 y/o – 300 – 400 mature oocytes @ 23 y/o – 180 – 280 mature ovum @ 33 y/o – 60 – 160 mature ovum @ 36 y/o – 24 – 124 mature ovum @46 y/o – 4 mature ovum
  13. 13. Fallopian Tube/Oviducts Interstitial – most dangerous site for ectopic pregnancy Isthmus – site for sterilization, site for BTL Ampulla – site of fertilization, common site for ectopic preg. Infundibulum – most distal part, trumpet shape, has fimbraeLBERT T. SALACUP RN,MSN
  14. 14. THE BONY PELVIS Support and protect the pelvic content I – nnominate bones S ac – rum Coc - cyx Muscular Floor of Bony Pelvis Levator ani Muscle I-liococcygeus Pubo- co- ccygeus Pubo-Re-ctalisGILBERT T. SALACUP RN,MSN Pubo-Va-ginalis
  15. 15. PELVIC TYPES Caldwell – Moloy ClassificationG – ynecoid –female pelvis,most favorable for Vaginal birthA – ndroid – male pelvis,not favorable for Vaginal birthA - nthropoid-ape,moderate narrow pubic arch,oval shapeP – latypelloid – flat, wide tranverse diameter,short ateroposterior diameterGILBERT T. SALACUP RN,MSN
  16. 16. MENSTRUATION E and POrgan for mens:  hypothalamus Stimulate hypothalamus  anterior pituitary gland  ovaries Release GnRH  uterus Stimulate APG FSH LH Maturation of ovum/folicle OvulationGILBERT T. SALACUP RN,MSN
  17. 17. E MENSTRUATION 14th day Stimulate hypothalamus E P Release GnRH Stimulate APG Ovulation/Rupture of Graafian Follicle/Ovulatory FSH BBT Spinbarkeit MittleschmerzMaturation ovum/follicle Stimulate Ovaries to relese E 15th day Graafian Follicle Start degenerateContains Secrete large amnt. Of E Mature To yelowis/corpus Luteum Ovum Proloferative/Folicularphase/pos Secrete large Amt. of P t mestrual/Pre-ovulatory phase Secretory/Luteal Phse/Postovulatory/Premenstrual 13th day 24th days E Peak level P Corpus Luteum Degenerate Stimulate hypothalamus Whitish/Corpus Albicans Release GnRH 28th days if no fertilization uterine begin to slough off Stimulate APG LH Sti. Ovaries to rel. Day 1 Menstruation Hormone for Ovulaion P 14th day
  18. 18. CYCLEOvarian Uterine/EndCycle ometrial CycleMenstrual MenstrualFollicular ProliferativeOvulatory SecretoryLuteal Ischemic GILBERT T. SALACUP RN,MSN
  19. 19. Estrogen “Hormone of the Woman” – Primary function: development secondary sexual characteristic female. Others: inhibit production of FSH ( maturation of ovum) hypertrophy of myometrium Spinnbarkeit & Ferning ( billings method/ cervical) development ductile structure of breast increase osteoblast activities of long bones increase in height in female causes early closure of epiphysis of long bones causes sodium retention increase sexual desire
  20. 20. Progesterone “ Hormone of the Mother” Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous (twisted) Secondary Function: uterine contractility (favors pregnancy) Others: 1.inhibit prod of LH (hormone for ovulation) 2.inhibit motility of GIT 3. mammary gland development 4. increase permeability of kidney to lactose & dextrose causing (+) sugar 5. causes mood swings in moms 6. increase BBT GILBERT T. SALACUP RN,MSN
  21. 21.  Average menstrual cycle – 28 days (short 22,long 35) Average menstrual period – 5 days ( 4-6 days) Normal blood loss – 50 cc/ ¼ cup ( 30-80cc) Related terminologies  Menarche – 1st menstruation  Dysmenorrhea – painful menstruation  Metrorrhagia – irregular but frequent menses  Menorrhagia – prolong menses at regular interval(Hypermenorrhea)  Menometrorrhagia-prolong utterine bleeding at irregular interval  Amenorrhea – absence of menstruation  Menopause – cessation of menstruation (Average Age- 51 y.o.)  Tofu – has isoflavone – estrogen of plant that mimics the estrogen with a woman GILBERT T. SALACUP RN,MSN
  22. 22. Male Reproductive SystemGILBERT T. SALACUP RN,MSN
  23. 23. EXTERNAL STRUCTURESPenisMa –le organ for copulationEl- ongated cylindrical structureB – odyCo- mposed ofCo –rpora cavernosa 2Co-rpus spongiosum GILBERT T. SALACUP RN,MSN
  24. 24. Scrotum P -ouch hanging below the pendulous penis, Co -ntains 2 sacs L–ess2 degrees C,than bodytemp. Co-oling mechanism of testes P- igmented w/ scattered hair Co-mposed skin and dartos muscleGILBERT T. SALACUP RN,MSN
  25. 25. Testes 2 solid ovoid organs 4-5 cm longand 2-3 wide, Leydig cells- testosterone production GILBERT T. SALACUP RN,MSN
  27. 27. The Process of Spermatogenesis Testes (900 coiled seminiferous tubules) ↓ epididymis 5% (site of maturation of sperm 6 m) ↓ Vas Deferens (conduit pathway of sperm) ↓ Seminal Vesicle 30% (secreted: fructose form of glucose, nutritative value Prostaglandin: causes reverse contraction of uterus) ↓ Ejaculatory Duct (conduit of semesn) ↓ Prostate Gland 60% (release alkaline substances) ↓ Cowpers Gland 5% (release alkaline substance) ↓ UrethraGILBERT T. SALACUP RN,MSN
  28. 28. SEMENIs a thick whitish fluid ejaculated by the male during orgasm, contains spermatozoa and fructose-rich nutrients. Seminal vesicle (30%) Epididymis ( 5%) Bulbourethral gland (5%) Prostate gland (60%) • Average pH = 7.5 • Ejaculation is 2.5 -5 ml. It can live with in the female genital tract for about 24 to 72 hours. • (50-200 million/ml of ejaculation ave. of 400 million/ejaculation ) • 90 seconds- cervix • 5 mins.- end of fallopian tube GILBERT T. SALACUP RN,MSN
  30. 30. Male Female Penile Glands Clitoris Penile Shaft Clitoral shaft Testes Ovaries Prostate Skene’s gland Cowper’s Glands Bartholin’s Gland Scrotum Labia Majora Stages of Sexual Responses F(EPOR) M(EXPLORR)Initial responses: Vasocongestion – congestion of blood vessels Myotonia – increase muscle tensionEx-citement Phase – (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) – erotic timuli cause increase sexual tension, lasts minutes to hours.Pl-ateau Phase –(accelerated V/S)–increasing & sustained tension nearing orgasm.Lasts 30 seconds – 3 min.O-rgasm – (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with physiologic or psychologic release, immeasurable peak of sexual experience. May last 2 – 10 sec- most affected are is pelvic area.R-esolution – (v/s return to normal, genitals return to pre-excitement phase)R-efractory Period – the only period present in males, wherein he cannot be restimulated for about 10-15 min. GILBERT T. SALACUP RN,MSN
  31. 31. Basic Knowledge on Genetics and Obstetrics  DNA – carries genetic code  Chromosomes – threadlike strands composed of hereditary material – DNA  Normal amount of ejaculated sperm - 3 – 5 cc., 1 tsp  Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation  Sperm is viable within 24 – 72 hrs, 2-3 days  Reproductive cells divides by the process of meiosis (haploid)  Spermatogenesis – maturation of sperm  Oogenesis – process - maturation of ovum  Gematogenesis – formation of 2 haploid into diploid 23 + 23 = 46 or diploid  Age of Reproductivity – 15 – 44yo  childbearing age – 20 – 35 y/o  High risk  <18 & >35 y.o.  With Risk  18 – 20; 30 – 35GILBERT T. SALACUP RN,MSN
  32. 32. FertilizationPhonones – song of spermCapacitation – ability of sperm to release proteolytic enzyme and penetrate the ovum Stages of Fetal G and D1.Pre Embryonic StageZygote  fertilized ovum (3 – 4 days travel, 4 days floating)> from fertilizationMorula  mulberry-liked ball containing 16 – 50 cellsBlastocyst  enlarging cell forming a cavity that later becomes the embryo covered by thropoblast which later becomes the placenta and membraneThropoblast – covering of blastocyst that become placentaImplantation  7 – 10 days after fertilization3 Processes1. Apposition 2. Adhesion 3. InvasionS/Sx of Implantation  Slight pain, Slight Vaginal SpottingGILBERT T. SALACUP RN,MSN
  33. 33. 2. Embryonic Stage Zygote – fertilization to 14 days Embryo – 15th – 2 mos/ 8 weeks Fetus – 2 mos to birth Decidua – thickened endometrium for pregnacy, latin word for “falling off” Basalis – located directly under the fetus where placenta developed Caspularis – encapsulates the fetus Vera – remaining portion of and endometrium GILBERT T. SALACUP RN,MSN
  34. 34. Chorionic Villi – 10 – 11 weeksChorionic Villi Sampling (CVS) – removal of tissue from the fetal postion of the developing placenta For genetic screening Fetal limb defects, missing digits of toes  Cytothrophoblast – outer layer, LANGHAN’S LAYER, protect the fetus against syphilis (24 weeks/ 6 months)  Synsitiotrophoblast – syncitial layer – responsible for hormone production (HCG,HPL,E & P) 1. Amnion – inner most layer 2. ChorionUmbilical cord (Funis) – whitish gray (50 – 60 cm) Short  abruptio placenta, uterine inversion Long  cord prolapse, cord coil 3 vessels (AVA) – Artery Vein Artery Wharton’s Jelly – protects the umbilical cord GILBERT T. SALACUP RN,MSN
  35. 35. Amniotic fluid  bag of water  clear color, musty/mousy odor With crystallized forming pattern, slightly alkaline 500- 1000 cc Normal Oligohydramnios – kidney malformation Polyhydramnios – GIT Functions  Cu -shion the fetus against sudden blow or trauma  H-elps in development process  Fa -cilitate muscuskeletal development  Ma -intains temperature  P-revents cord compression   GILBERT T. SALACUP RN,MSN
  36. 36. Diagnostic Test for Amniotic Fluid  AmniocentesisPurpose: obtain sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac1. Genetic screening maternal serum alpha feto-protein test (MSAFP) – 1st trimester2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity – 3rd trimester Testing time – 36 weeks - Done with empty bladderdecreased MSAFP= down syndromeincrease MSAFP = spina bifida or open neural tube defect Complication > Most common side effect : INFECTION > Late : pre term labor > Early : spontaneous abortionIndication for Amniocentesis: > Early in Pregnancy Advance Maternal Age > Later in Pregnancy Diabetic Mothers Greenish – Meconium Stains (Fetal Distress) Yellowish – jaundice, hyperbilirubinemia Cloudy – Infection GILBERT T. SALACUP RN,MSN
  37. 37. Most Important Consideration  Needle insertion site Amnioscopy – direct visualization or exam to an intact fetal membrane. Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid) Nitrazine Paper Test – diff amniotic fluid & urine. Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid.Lecithin Sphingomyelin L/SRatio- 2:1 signifies fetal lung maturity not capable for RDS Shake test – amniotic + saline & shakeDefinitive test - Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity GILBERT T. SALACUP RN,MSN
  38. 38. Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis. Size: 500g or ½ kg , 1 inch thick & 8” diameter Functions of Placenta:  Respiratory System – beginning of lung function after birth of baby. Simple diffusion  GIT – transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic  Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.  Circulating system – achieved by selective osmosis  Endocrine System – produces hormones  Human Chorionic Gonadrophin – maintains corpus luteum alive.  Human placental Lactogen or sommamommamotropin Hormone – for mammary gland development.  Has a diabetogenic effect – serves as insulin antagonist  Relaxin Hormone- causes softening joints & bones  estrogen  progestin  It serves as a protective barrier against some microorganisms – HIV,HBVGILBERT T. SALACUP RN,MSN
  39. 39. Germ Layer Ectoderm  Brain  Peripheral NS/CNS  Skin, Sebaceous gland  Mammary Gland  5 senses  Hair, nails  Anus,Mouth,Nose  Tooth Enamel Mesoderm  Bones, Muscles, Tendons  Dentin of the teeth  Heart/Circulatory syatem  Lymph vessels  Musculoskeletal  Reproductive Organ  Kidney, Ureters Endoderm  Lower GUT,Bladder, Urethra  Thyroid – responsible for basal metabolism  Thymus – immunity  Liver  Lining of pericardial, Pleural  Linings of Upper GI Tract GILBERT T. SALACUP RN,MSN
  40. 40. First trimester: Fifth Month lanugo covers body1st month - Brain & heartdevelopment actively swallows amniotic fluid GIT& resp Tract – remains as single tube Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18wks multi1. Fetal heart tone begins – heart is the oldest part of fetal heart tone heard with or without instrument Vernix Caseosa appear the body Sleep wake patern2. CNS develops – dizziness of mom due to hypoglycemic effect Embrayo Length – 16-18.5cm; Wt – 300g pregnant womans food (potato)Embrayo Length – 0.4cm; Wt – 0.4g Sixth Month eyelids openSecond Month Hearing responseAll vital organs formed, placenta developed Active production of lung surfactantCorpus luteum – life span – end of 2nd month wrinkled skinSex organ formed vernix caseosa present Embrayo Length – 23cm; Wt – 600gMeconium is formedHeart beats rhythmically Third trimester: Period of most rapid growth.FOCUS: weight of fetus Embrayo Length – 2.5cm; Wt – 2g Seventh Month – development of surfactant – lecithinThird Month Lung alveoli mature Testes begins to descendKidneys functional Embrayo Length – 27cm; Wt – 1100gBuds of milk teeth appear Eighth MonthFetal heart tone heard – Doppler – 10 – 12 weeks lanugo begin to disappearSex is distinguishable Moro reflexEmbrayo Length – 6-8cm; Wt – 19g sub Q fats deposit Delivery positioned Second Trimester:FOCUS–length of fetus  Nails extend to fingersFourth Month Embrayo Length – 31cm; Wt – 1800-2100gBabinski reflex Ninth Monthfetal heart tone heard fetoscope, 18 – 20 weeks lanugo & vernix caseosa completely disappear Sole of the foot with creasesbuds of permanent teeth appear Definite sleep/wake paternSex differentiation Complete and can determine by Amniotic fluid decreases ultrasound Embrayo Length – 35cm; Wt – 2200-2900gEmbrayo Length – 11.5-13.5cm; Wt – 55-120g Tenth Month – bone ossification of fetal skull  Testes decended Active Sucking GILBERT T. SALACUP RN,MSN Embrayo Length – >40cm; Wt – >3200g
  41. 41. PREGNANCY– 266 – 294 days/ 37 – 42 weeks Ave. 40wksPeriod of viability - 24wksAbortus – less than 20wksTerratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus Drugs:Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing & deafnessTetracycline – staining tooth enamel, inhibit growth of long boneVitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundiceIodides – enlargement of thyroid or goiterThalidomides – Amelia or pocomelia, absence of extremitiesSteroids – cleft lip or palateLithium – congenital malformationAlcohol – lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by microcephalySmoking – low birth rateCaffeine – low birth rateCocaine – low birth rate, abruption placenta GILBERT T. SALACUP RN,MSN
  42. 42. TORCH (TERRATOGENIC) INFECTIONS – VIRUSEST – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meatO – others. Hepa A,Hepa B, HIV, SyphilisR – rubella – German measles – congenital heart disease, Cleft palate and lip Don’t get pregnant for 3 months. Vaccine is terratogenicC – cytomegalo virus – droplet infection, s/s asymtomatic, microcephaly, hydrocephalusH – herpes simplex virus –1st tri – congenital anomalies and spontaneous miscarriage2nd and 3rd = Premature birth, intrauterine growth Retardation, CS. GILBERT T. SALACUP RN,MSN
  43. 43. PHYSIOLOGICAL ADAPTATION OF THE MOTHER TO PREGNANCY A. Systemic Changes1. Cardiovascular System – increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc of blood- easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis – due to hyperemia of nasal membrane palpitation, Physiologic Anemia – pseudo anemia of pregnant womenNormal ValuesHct 32 – 42%Hgb 10.5 – 14g/dL   Pathogenic Anemia Iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women. - Assessment reveals:  Pallor, constipation  Slowed capillary refill  Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia  GILBERT T. SALACUP RN,MSN
  44. 44. NURSING CARE: Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetable-alugbati,saluyot, malunggay, horseradish, ampalaya Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered, hematoma. Oral Iron supplements ( 60mg/day) empty stomach 1 hr before meals or 2 hrs after, black stool, constipation Monitor for hemorrhage Alert: Iron from red meats is better absorbed iron form other sources Vit CGILBERT T. SALACUP RN,MSN
  45. 45. Edema – lower extremities due venous return is constricted due to large belly, elevate legs above hip level. Varicosities – pressure of uterususe support stockings, avoid wearing knee high socksuse elastic bandage – lower to upper Vulbar varicosities- painful, pressure on gravid uterusHxTx: side lying with pillow under hips or modified knee chest position Thrombophlebitis – presence of thrombus at inflamed blood vesselincrease fibrinogenincrease clotting factorPt sign – (+) Homans sign – pain on cuff during dorsiflexionmilk leg – skinny white legs due to stretching of skin caused by inflammation GILBERT T. SALACUP RN,MSN
  46. 46. Respiratory system – common problem DOB due to enlarged uterus & increase O2 demandPosition- lateral expansion of lungs or side lying position. Gastrointestinal – 1st trimester changeMorning Sickness – nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon - small freq feeding. Vomiting in preg – emesisgravida.Metabolic alkalosis, F&E imbalance – primary med mgt – replace fluids.. Monitor I&OConstipation – progesterone response for constipation. Increase fluid intake, increase fiber diet- fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.- exercise* Flatulence – avoid gas forming food – cabbage * Heartburn – or pyrosis- small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanicalincrease salivation – ptyalsim – mgt mouthwash*Hemorrhoids – pressure of gravid uterus. Mgt; hot sitz bath for comfort Urinary SystemAcetyace test – albumin in urineBenedicts test – sugar in urine  GILBERT T. SALACUP RN,MSN
  47. 47. MusculoskeletalLordosis – pride of pregnancyWaddling Gait – awkward walking due to relaxation – causes softening of joints & bonesProne to accidental falls – wear low heeled shoesLeg Cramps – causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause while pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab. Vit D for increased Ca absorption, dorsiflexion GILBERT T. SALACUP RN,MSN
  48. 48. Local change: Vagina:V – C - hadwick’s sign – blue violet discoloration of vaginaI – He - gars – change of consistency of isthmus (lower uterine segment)C – Go - odels sign – change of consistency of cervix LEUKORRHEA – whitish gray, mousy odor dischargeESTROGEN – hormone, resp for leucorrheaOPERCULUM – mucus plug to seal out bacteria.PROGESTERONE – hormone responsible for operculumPREGNANT – acidic to alkaline change to protect bacterial growth (vaginitis)  GILBERT T. SALACUP RN,MSN
  50. 50. Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory)First Trimester: ( I am Pregnant)Focus: bodily changes of preg, nutritionNo tanginal signs & sx, surprise, ambivalence, denial – sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy Second Trimester – ( Im Going to have a Baby)tangible S&Sx. mom identifies fetus as a separate entity – due to presence of quickening, fantasy. Developmental task – accept growing fetus as baby to be nurtured.Health teaching: growth & development of fetus. Third Trimester: - ( Im Going to be a parent)mom has personal identification on appearance of babyDevelopment task: prepare of birth & parenting of child. HT: responsible parenthood ‘baby’s Layette” – best time to do shopping.Most common fear – let mom listen to FHT to allay fear  GILBERT T. SALACUP RN,MSN
  51. 51. Psychological task of the fatherFirst Trimester: Excitement predominate his behavior Confused and left out Couvade syndromeSecond Trimester: Anxiety is lessen Change in appearance of the partner Third Trimester:Rewarding time GILBERT T. SALACUP RN,MSN
  52. 52. Pre-Natal Visit:Frequency of Visit:1st 7 months – 1x a month8 – 9 months – 2 x a month10 – once a weekPost term - 2 x a week HBMR. Home base mom’s record. Couvade syndrome – dad experiences what mom goes through – lihi) Diagnosis of Pregnancy Urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6 weeks after LMP- best to get urine exam. Elisa test – test for preg detects beta subunit of HCG as early as 7 – 10days Home preg kit – do it yourself GILBERT T. SALACUP RN,MSN
  53. 53. Weight MonitoringFirst Trimester:Normal Weight gain :1.5 – 3 lbs (1lb/month) :1kgSecond trimester:normal weight gain:10 – 12 lbs(4 lbs/month) (1 lb/wk) : 5kgThird trimester:normal weight gain :10 – 12 lbs(4 lbs/ month) ( 1lb/wk): 5kg Minimum wt gain – 20 – 25 lbs Optimal wt gain – 25 – 35 lbs   GILBERT T. SALACUP RN,MSN
  54. 54. Obstetrical Data: Gravida- # of pregnancyPrimigravida – pregnant for the 1st timeMultigravida – Pregnant 2 – 5th timesGrandMultigravida- 6th aboveNulligravida – Never been pregnant Para - # of viable pregnancy( 20wks AOG)Primipara – 1st birth to baby Beyond/more than 20wks AOGMultipara – 2-5th births to baby Beyond/more than 20wks AOGGrandMultipara – 6th above births to baby Beyond/more than 20wks AOGNullipara- not given birth to baby Beyond/more than 20wks AOGage of viability - 20 – 24 wksTerm - 38 – 42 wks,Preterm -20 – 37 weeksabortion <20 weeks GILBERT T. SALACUP RN,MSN
  55. 55. G – ravida = # of PregnancyT- erm = # of TermP-reterm = # of PretermA-bortion = # of AbortionsL – iving = # of Living Nagele’s RuleUse to determine expected date of deliveryJan – Mar  +9 months +7 daysApr – Dec  -3 months +7 days + 1 year GILBERT T. SALACUP RN,MSN
  56. 56. McDonald’s Rule Determines age of gestation in weeks FUNDIC HT X 7/8=AOG in WK Fundic Ht X 7 = AOG in weeks 8Ex.Fr sypmhisis pubis to fundus 24 X 7 =21 wks 8 GILBERT T. SALACUP RN,MSN
  57. 57. Bartholomew’s RuleDetermines age of gestations 3 mos –above pubis symphysis ½ from umbilicus 4 mos – ¾ from umbilicus 5 mos – level of umbilicus 6 mos – ¼ from umbilicus to xyphoid process 7 mos – ½ from umbilicus to xyphoid process 8 mos – ¾ from umbilicus to xyphoid process 9 mos – just the xyphoid process 10 mos – level of 8th mosGILBERT T. SALACUP RN,MSN
  58. 58. Haases rule to determine length of the fetus in cm.Formula: 1st ½ of preg , square @ month 2nd ½ of preg, x @ month by 53mos x 3 = 9cm4 mos x 4 = 16 cm 1st ½ of preg5 x 5 = 25 cm 6 x 5 = 30 cm7 x 5 = 35 cm 2nd ½ of preg8 x 5 = 40 cm9 x 5 = 45 cm10 x 5 = 50 cm GILBERT T. SALACUP RN,MSN
  59. 59. Disease Vaccine Minimum Age Dose Route Site Percent Duration of Protection Interval Protected Tetanus TT1 At 5th – 6th month of 0.5 ml Deep intra – Deltoid region 80% Varies 1 yr pregnancy muscular of the arm TT2 At least 4 wks after 0.5 ml Deep intra – Deltoid region 80% - Infants born will TT1 muscular of the arm be protected from neonatal tetanus. - 3 yrs protection for the mother. TT3 At least 5-6 mons. 0.5 ml Deep intra – Deltoid region 90% - Infants born will later of 2nd muscular of the arm be protected from neonatal tetanus. pregnancy regardless of - 5 yrs. Protection interval for the mother. TT4 At least 5-6 mons. 0.5 ml Deep intra – Deltoid region 99% - Infants protected Of 3rd pregnancy. muscular of the arm from Neonatal Tetanus. Regardless of interval` - 10 yrs. Protection for the mother. TT5 At least 5-6 mons. 0.5 ml Deep intra – Deltoid region 99% -lifetime Of 4th pregnancy. muscular of the arm protection. Regardless of - All infants born interval` to that mother will be protected.GILBERT T. SALACUP RN,MSN
  60. 60. Danger Signs of PregnancyA - bdominal Pain  epigastric pain  auro of impending convulsionB - oardlike Abdomen  Abruptio placentaB - lurred Vission  pre eclampsia - Scotoma – spots in the eyeB - leeding  abortion/ ectopic pregnancy – 1st trimester  H Mole/ Incompetent Cervix – 2nd trimester  Placental Anomalies – 3rd TrimesterB-P↑C - hills & Fever,C - erebral DisturbancesD- ischarge ( Mabaho)E-demaF-luid – sudden gush – PROM premature rupture of membraneG-rabeng Pagsusuka - GILBERT T. SALACUP RN,MSN
  61. 61. Pelvic ExaminationIE – empty bladder, precautionPosition : dorsal recumbent, lithotomy Pap smear – done 1st visitCytological exam – determine presence of cancer cells. Result : Class I – normal Class II A – cytology without evidence of malignancy B – suggestive of inflammation Class III – cytology suggestive of malignancy Class IV – cytology suggestive og malignancy Class V – conclusive for malignancyMost common cancer report organ : cervical cancerMost common site for pap smear – external OS of cervix (squamocolumnar tissue)Common site of cervical cancer. maternal – speculum (open)Stages of cervical cancer 0 – carcinoma in situ 1 – Ca strictly confined to cervix 2 – from cervix extends to the vagina 3 – pelvic metastasis 4 – affectation to bladder & rectum GILBERT T. SALACUP RN,MSN
  62. 62. LEOPOLD’S MANNEUVERLM1 - fundic grip - determine the presenting partsLM2 – abdominal/umbilical grip – Fetus back  PR of mother : uterine soufflé – MHR  fundic soufflé – FHRLM3 – Pawlik’s grip - To determine degree of engagement.LM4 - pelvic grip –Attitude –Full Flexion – when the chin touches the chest GILBERT T. SALACUP RN,MSN
  63. 63. Assessment of Fetal Well-BeingDaily Fetal Movement Counting (DFMC) –begin 27 weeks Mom- begin after meal - breakfasta. Cardiff count to 10 method – one method currently available(1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs)(2) Expected findings – 10 movements in 1 hour or less3) Warning signs a.) more than 1 hour to reach 10 movements b.) less than 10 movements in 12 hours(non-reactive- fetal distress) c.) longer time to reach 10 FMs than on previous days d.) movement are becoming weaker, less vigorous Movement alarm signals - < 3 FMs in 12 hours4.) warning signs should be reported to healthcare provider immediately; often require further testing. Examples: nonstress test (NST), biographical profile (BPP)  GILBERT T. SALACUP RN,MSN
  64. 64. Nonstress test to determine the response of the fetal heart rate to activityIndication pregnancies at risk for placental insufficiency Postmaturity  pregnancy induced hypertension (PIH), diabetes  warning signs noted during DFMC  maternal history of smoking, inadequate nutrition Procedure:Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor); external monitor is applied to document fetal activity; mother activates the “mark button” on the electronic monitor when she feels fetal movement.Attach external noninvasive fetal monitors 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 20 minutes  if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen  if no FM after 1 hour further testing may be indicated, contraction stress test (CST)Result : Nonreative Nonstress Not Good Reactive Response is Real Good GILBERT T. SALACUP RN,MSN
  65. 65. Interpretation of resultsReactive result  Baseline FHR between 120 and 160 beats per minute  At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds in a 10 to 20 minute period as a result of FM  Good variability – normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip.  result indicates a healthy fetus with an intact nervous systemNonreactive result Stated criteria for a reactive 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) GILBERT T. SALACUP RN,MSN
  66. 66. Recommended Nutrient Requirement that increases During Pregnancy Nutrients Requirements Food SourceCalories 300 calories/day above the Caloric increase should reflectEssential to supply energy for prepregnancy daily -Foods of high nutrient value such as-Growth of fetus Development of -Begin increase in second trimester. protein, complex carbohydrates -Failure to meet caloric requirements (whole grains, vegetables, fruits)structures required for pregnancy can lead to ketosis ketosis has been -No more than 30% fatincluding placenta, amniotic fluid, associated with fetal damage.and tissue growth.Protein 60 mg/day or an increase of 10% Protein increase should reflectEssential for: above daily requirements for age -Lean meat, poultry, fish-Fetal tissue growth group -Eggs, cheese, milk-Maternal tissue growth including Adolescents have a higher protein -Dried beans, lentils, nutsuterus and breasts requirement than mature women -Whole grains-Formation of red blood cells and since adolescents must supply protein * vegetarians must take note of theplasma proteins for their own growth as well as amino acid content of CHON foods* Inadequate protein intake has been protein t meet the pregnancy consumed to ensure ingestion ofassociated with onset of pregnancy requirement sufficient quantities of all aminoinduces hypertension (PIH) acids GILBERT T. SALACUP RN,MSN
  67. 67. Calcium-Phosphorous - 1200 mg/day representing an increase Calcium increases should reflect:Essential for of 50% above prepregnancy daily -dairy products : milk, yogurt, ice cream,-Growth and development of fetal skeleton requirement. cheese, egg yolkand tooth buds - 1600 mg/day is recommended for the -whole grains, tofu-Maintenance of mineralization of maternal adolescent. 10 mcg/day of vitamin D -green leafy vegetablesbones and teeth -canned salmon & sardines w/ bones-Current research is : -Ca fortified foods such as orange juiceDemonstrating an association between -Vitamin D sources: fortified milk,adequate calcium intake and the prevention margarine, egg yolk, butter, liver, seafoodof pregnancy induce hypertensionIron 30 mg/day representing a doubling of the Iron increases should reflectEssential for pregnant daily requirement -liver, red meat, fish, poultry, eggs -Begin supplementation at 30- mg/day in second -enriched, whole grain cereals and breads-Expansion of blood volume and red trimester, -60 – 120 mg/day along with copper and zinc who -dark green leafy vegetables, legumesblood cells formation -nuts, dried fruits have iron deficiency anemia.-Establishment of fetal iron stores for -70 mg/day of vitamin C which enhances iron -vitamin C sources: citrus fruits & juices,first few months of life absorption strawberries, cantaloupe, broccoli or * iron deficiency anemia is the most common cabbage, potatoes nutritional disorder of pregnancy.Zinc 15mcg/day representing an increase of Zinc increases should reflectEssential for 3 mg/day over prepreganant daily -liver, meats* the formation of enzymes requirements. -shell fish* maybe important in the prevention -eggs, milk, cheeseof congenital malformation of the -whole grains, legumes, nutsfetus.Folic Acid, Folacin, Folate 400 mcg/day representing an increase of Increases should reflectEssential for more then 2 times the daily prepregnant -liver, kidney, lean beef, veal-formation of red blood cells and prevention requirement. 300mcg/day supplement for -dark green leafy vegetables, broccoli,of anemia women with low folate levels or dietary legumes.-prevention of neutral tube defects (spina deficiency -Whole grains, peanutsbifida), abortion, abruption placenta 4 servings of grains/day GILBERT T. SALACUP RN,MSN
  68. 68. Additional Requirements Increased requirements ofMinerals pregnancy can easily be-iodine met with a balanced diet-Magnesium 175 mcg/day that meets the-Selenium 320 mg/day requirement for calories 65 mcg/day and includes food sources high in the other nutrients needed during pregnancy.Vitamins Vit stored in body.E 10 mg/day Taking it not needed – fatThiamine 1.5 mg/day soluble vitamins. Hard toRiborlavin 1.6 mg/day excrete.Pyridoxine ( B6) 2.2 mg/dayB12 2.2 mg dayNiacin 17 mg/day GILBERT T. SALACUP RN,MSN
  69. 69. Sexual Activity  should be done in moderation  should be done in private place  mom placed in comfy pos, sidelying or mom on top  avoided 6 weeks prior to EDD  avoid blowing or air during cunnilingus  changes in sexual desire of mom during preg- air embolismChanges in sexual desire:1st tri – decrease desire – due to bodily changes2nd trimester – increased desire due to increase estrogen that enhances lubrication3rd trimester – decreased desire Contraindication in sex:1. vaginal spotting 1st trimester – threatened abortion 2nd trimester– placenta previa2. incompetent cervix3. preterm labor4. premature rupture of membrane GILBERT T. SALACUP RN,MSN
  70. 70. Exercise strengthen muscle to be used during the delivery processWalking – best form of exerciseSquatting – strengthen perineum & ↑circulation to the perineum (raise the buttocks before head to prevent postural hypotension)Tailor sitting – same purpose with squatting ( Indian seat)Kegel exercise – strengthen pubococcygeal muscleAbdominal exercise – muscle of the abdomen ( done as if blowing a candle)Shoulder circling exercise – strengthen muscle of the chestPelvic rocking exercise or pelvic tilt – relieve low back pain & maintain good posture (arching back for 3 sec) Principles of exercise  must be done in moderation  must be individualized GILBERT T. SALACUP RN,MSN
  71. 71. Psychoprophylaxis – prevention of pain1. Lamaze: Dr. Ferdinand Lamaze req. disciple, conditioning & concentration. Husband is coachFeatures: Conscious relaxation Cleansing breathe – inhale nose, exhale mouth Effleurage – gentle circular massage over abdominal to relieve pain imaging – sensate focus Psychophysical1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery process. Based on imitation of nature.Features: 1.) darkened rm 2.) quiet environment 3.) relaxation tech 4.) closed eye & appearance of sleep2. Grantly Dick Read Method – fear leads to tension while tension leads to pain Psychosexual1. Kitzinger method – preg, labor & birth & care of newborn is an impt turning pt in woman’s life cycle- flow with contraction than struggle with contraction   GILBERT T. SALACUP RN,MSN
  72. 72. Different Methods of deliverybirthing chair – bed convertible to chair – semifowlersbirthing bed – dorsal recumbent possquatting – relives low back pain during labor painleboyers – warm, quiet, dark, comfy room. After delivery, baby gets warm bath.Birth under H20 – bathtub – labor & delivery – warm water, soft music. Intrapartal Notes – inside ER Admitting the laboring MotherPersonal Data: name, age, address, etcBaseline Data: v/s esppecially BP, weightObstetrical Data: gravida # preg, para- viable preg, – 22 – 24 wksPhysical Exams, Pelvic Exams GILBERT T. SALACUP RN,MSN
  73. 73. Basic knowledge in Intrapartum. Theories of the Onset of Labor1.) uterine stretch theory( any hallow organ stretched, will always contract & expel its content) – contraction action2.) oxytocin theory– post pit gland releases oxytocin. Hypothalamus produces oxytocin3.) prostaglandin theory– stimulation of arachidonic acid – prostaglandin- contraction4.) progesterone theory– before labor, decrease progesterone will stimulate contractions & labor5.) theory of aging placenta– life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).  GILBERT T. SALACUP RN,MSN
  74. 74. THE 5 P’S OF LABOR 1.PassengerFetal head –is the largest presenting part – common presenting part – ¼ of its length.Bones – 6 bonesE – ethmoidS – sphenoidO – occuputal – occiputF – frontal – sinciputT – temporalP – parietal 2 x   GILBERT T. SALACUP RN,MSN
  75. 75. Measurement fetal head1. transverse diameterbiparietal – largest transverse 9.25cmBitemporal - 8 cmbimastoid - 7cm smallest transverse2.AP diameterSuboccipitobregmatic – complete flexionOccipitofrontal – partial flexion - 12cmOccipitotemporal – largest AP diameter; hyperextended (13.5cm)Submentobrgmatic - face presentation; poor flexioGILBERT T. SALACUP RN,MSN
  76. 76. Sutures intermembranous spaces that allow molding. sagittal suture – connects 2 parietal bones ( sagitna) coronal suture – connect parietal & frontal bone (crown) lambdoidal suture – connects occipital & parietal bone Moldingsthe overlapping of the sutures of the skull to permit passage of the head to the pelvis GILBERT T. SALACUP RN,MSN
  77. 77. Fontanels2.Anterior fontanel bregma, diamond shape 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close2.Posterior fontanel or lambda – triangular shape 1 x 1 cm. Closes – 2 – 3 months. GILBERT T. SALACUP RN,MSN
  78. 78. Passageway – vagina & pelvis Pelvis 4 main pelvic types Gynecoid – Android – Anthropoid-Platypelloid Problem :  mother who encounter accident  ↓ 4’9”  ↓ 18y/o – R: pelvis not achieve its full pelvic growth 4 Bones of pelvis1.2 hip bones – 2 innominate bones 3 Parts of 2 Innominate Bones Ileum – lateral side of hips Iliac crest – flaring superior border forming prominence of hips Ischium – inferior portion - ischial tuberosity where we sit – landmark to get external measurement of pelvis Pubis – ant portion – symphisis pubis junction between 2 pubis2.1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis3.1 coccyx – 5 small bones compresses during vaginal delivery GILBERT T. SALACUP RN,MSN
  79. 79.  Important Measurements1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis pubis. Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true GILBERT T. SALACUP RN,MSN conjugate)2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm 3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more. Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above.
  80. 80. Power– the force acting to expel the fetus and placenta – myometrium – powers of labora. Involuntary Contractionsb. Voluntary bearing down effortsc. Characteristics: wave liked. Timing: frequency, duration, intensity Psyche/Person– psychological stress when the mother is fighting the labor experiencea. Cultural Interpretationb. Preparationc. Past Experienced. Support System  GILBERT T. SALACUP RN,MSN
  81. 81. Physiologic Changes Preceding Labor- shooting pain radiating to the legs- urinary freq. Lightening – setting of presenting part into pelvic brim - 2 weeks prior to EDD * Engagement- setting of presenting part into pelvic inlet2. Braxton Hicks Contractions – painless irregular contractions3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase epinephrine4. Ripening of the Cervix – butter soft5. decreased body wt – 1.5 – 3 lbs6. Bloody Show – pinkish vaginal discharge – blood & leukorrhea7. Rupture of Membranes – rupture of water. Check FHT GILBERT T. SALACUP RN,MSN
  82. 82. Premature Rupture of Membrane ( PROM) - do IE to check for cord prolapse Contraction drop in intensity even though very painful Contraction drop in frequently Uterus tense and/or contracting between contractions Abdominal palpations  Nursing Care; Administer Analgesics (Morphine) Attempt manual rotation for ROP or LOP – most common malposition Bear down with contractions Adequate hydration – prepare for CS Sedation as ordered Cesarean delivery may be required,especially if fetal distress is noted GILBERT T. SALACUP RN,MSN
  83. 83. Cord Prolapsea complication when the umbilical cord falls or is washed through the cervix into the vagina. Danger signs: PROM Presenting part has not yet engaged Protruding cord form vagina Fetal distress Nursing care: Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy. Slip cord away from presenting part Count pulsation of cord for FHT Prep mom for CS Positioning – trendelenberg or knee chest position Emotional support Prepare for Cesarean Section GILBERT T. SALACUP RN,MSN
  84. 84. Difference Between True Labor and False Labor False Labor True LaborIrregular contractions Regular ContractionsNo increase in intensity Increased intensityPain – confined to abdomen Pain – begins lower back radiates to abdomenPain – relived by walking Pain – intensified by walkingNo cervical changes Cervical effacement & dilatation * major sxof true labor. Duration of Labor Primipara – 14 hrs & not more than 20 hrs Multipara – 8 hrs & not > 14 hrs Effacement – softening & thinning of cervix. Use % in unit of measurement Dilation – widening of cervix. Unit used is cm. GILBERT T. SALACUP RN,MSN
  85. 85. First StageOnset of true contractions to Full dilation and effacement of cervixGILBERT T. SALACUP RN,MSN
  86. 86. Stages of Labor Phase Characteristic Nursing CareLatent Phase Beginning to 3 cm dilatation. C-hest breathingDilations: Contraction: mild to short A-mbulation/walking0 – 3 cm 20-40/sec S-uppot person 6hr in nullipara 4-5hrs in multi E-ncorage voiding q 2-3 hrsActive Phase: Stronger contractions O-ral careDilations 40-60sec q 3-5 min M-edication be readied4 -7 cm 3hrs in nulli A-sses v/s-Abdominal 2hrs in multi BreathingTransitional 9cm full dilatation T-ired-loss sense of controlPhase: Very strong contraction I- nform the progress oflaborDilations 60-90 sec R-estless- support her w/t8 – 10 cm breathing tech. GILBERT T. SALACUP RN,MSN
  87. 87. Hyperesthesia increase sensitivity to touch, pain all over Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain keep informed of progress controlled chest breathing Nursing Care:T – iresI – nform of progressR – estless support her breathing techniqueE – ncourage and praiseD – iscomfort GILBERT T. SALACUP RN,MSN
  88. 88. Monitoring the Contractions and Fetal heart ToneSpread fingers lightly over fundus – to monitor contractions Parts of contractions:Increment or crescendo – beginning of contractions until it increasesAcme or apex – height of contractionDecrement or decrescendo – from height of contractions until it decreasesDuration – beginning of contractions to end of same contractionInterval – end of 1 contraction to beginning of next contractionFrequency – beginning of 1 contraction to beginning of next contractionIntensity - strength of contraction Contraction vasoconstrictionIncrease BP, decrease FHTBest time to get BP & FHT just after a contraction or midway of contractions Placental reserve – 60 sec o2 for fetus during contractionsDuration of contractions shouldn’t >60 sec Notify MD  GILBERT T. SALACUP RN,MSN
  89. 89. Pelvic Exams Effacement Dilationa. Station – landmark used: ischial spine- 1 station = presenting part 1cm above ischial spine if (-) floating- 2 station = presenting part 2 cm above ischial spine if (-) floating 0 station = level at ischial spine – engagement+ 1 station = below 1 cm ischial spine+3 to +5 = crowning – occurs at 2nd stage of labor GILBERT T. SALACUP RN,MSN
  90. 90. Presentation/liethe relationship of the long axis (spine) of the fetus to the long axis of the mother -spine of mom and spine of fetusTwo types:b.1. Longitudinal Lie ( Parallel)cephalic - Vertex – complete flexion Face Brow Poor Flexion ChinBreech - Complete Breech – thigh breast on abdomen, breast lie on thigh Incomplete Breech – thigh rest on abdominal Frank – legs extend to head Footling – single, double Kneelingb.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation. GILBERT T. SALACUP RN,MSN
  91. 91. Position – relationship of the fetal presenting part to specific quadrant of the mother’s pelvis.ROA/LOAleft occipito anterior most common & favorable positionROT/LOT – left occipito transverseROP/LOP – left occipito posterior  L/R- side of maternal pelvisMiddle – presenting partROP/ROT – most common malpositionROP/LOP – most painful mgt: pelvis squattingBreech – sacroplace the stethoscope above the umbilicusChin – mentumShoulder – acromnio dorso GILBERT T. SALACUP RN,MSN
  92. 92. NURSING CONSIDERATION DURING THE FIRST STAGE OF LABORBa - th is necessaryR -est on left side lying positionP -erennial preparation (rule of 7)M -onitor VS especially BPE -nema Purpose Cleanse the bowel Prevent infection 12 – 18 inches normal length of tube Lateral sims positionE -ncourage mother to voidN -PO FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen GILBERT T. SALACUP RN,MSN
  93. 93. For Pain Systemic analgesic DEMEROL (Meperidine HCl)  Narcotic and antispasmonic  Don’t give during latent phase  Given @ 6-8 cm dilated  Respiratory depression  Narcan (Naloxone, nalorfan, nalline)  Antidote for toxicity  Injected on the baby Epidural Anesthesia Hypotension Prehydrate the client to prevent hypotension In case of Hypotension Elevate leg Fast Drip IV GILBERT T. SALACUP RN,MSN
  95. 95. SECOND STAGE OF LABOR (FETAL STAGE) PRIMI – transfer to DR @ 10 cm dilatation MULTI – transfer to DR @ 7 – 8 cm dilatation Position in lithotomy both legs at the same timeBULGING OF PERENIUM  surest sign of delivery initiationPANT & BLOW Breathing- fetal pushing should be done on an open glottisMechanism of Labor (ED FIRE RERE)E -ngagementD-escentF-lexionI-nternal R-otationE-xtensionR-estitutionE-xternal R-otationE-xpulsion GILBERT T. SALACUP RN,MSN
  96. 96. Respiratory alkalosis  Due to incorrect breathing  Hyperventilation  S/sx  ↑ RR  Lightheadedness  Tingling sensation  Carpopedal spasm  Circumoral numbness Episiotomy Prevent laceration Widen the vaginal canal Shortens the 2nd stage of labor2 types  MEDIAN  Less bleeding  Less pain  Easy repair  Possible urethroanal fistula  major disadvantage  MEDIOLATERAL  More bleeding  More pain  Hard to repair and slow healing  GILBERT T. SALACUP RN,MSN
  97. 97. PELVIS Two Major Divisions of PelvisTrue pelvis – below the pelvic inletFalse pelvis – above the pelvic inlet; supports uterus during pregnancy  Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis.Nursing Care MODIFIED RIGEN’S MANEUVER  Done by supporting the perenium with a towel during delivery  Facilitates complete flexion  Avoids laceration First intervention: Support the head and suction secretion Do not milk the cord, wait for pulsation to stop before cutting When there is still birth, let the mother see the baby to accept the finality of death GILBERT T. SALACUP RN,MSN
  98. 98. THIRD STAGE OF LABOR (PLACENTAL STAGE) Birth of Infant to Placental Expulsion 3 – 10 minutes after child birthGILBERT T. SALACUP RN,MSN
  99. 99. CALKIN’S SIGN - 1st sign  Fundus rises Signs of Placental Separation  Fundus becomes globular and rises  calkin’s sign  Lengthening of the cord  Sudden gush of bloodBRANT – ANDREW’S MANEUVER  slowly pulling the cord and wind at the clamp  rapidly  may cause uterine inversionTypes Placental DeliverySHULTZ (Shiny)  From center to the edges  Presenting fetal sideDUNCAN (Dirty)  Form edges to center  Presenting the maternal side   GILBERT T. SALACUP RN,MSN
  100. 100. Nursing Considerations during placental deliveryCheck - placental completenesCheck -Fundus – Massage if BoggyCheck -BPM-ethergine, methylergonovine mallate (IM)O-xytocin (IV) if methergine is not presentC-heck perenium for lacerationsA-ssist in episioraphyV-aginoplasty/ Vaginal Landscape – Virgin againE-ncourage Flat on bed Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.  GILBERT T. SALACUP RN,MSN
  101. 101. FOURT STAGE OF LABOR (Recovery Stage) Immediate post Partum First 1 – 2 hours after delivery of placentaGILBERT T. SALACUP RN,MSN
  102. 102.  Maternal observation – body system stabilize  1st hour – q15 min 2nd hour - q 30 min Placement of fundus  In between umbilicus and pubis symphysis  Check bladder, assist in voiding, May lead to uterine atony  hemorrhage Types Color Day Composition Rubra Red 1-3 days Blood,WBC,Decidua, Some Lochia microorganism Serosa Pink 4-9 days Blood,mucus, tissue and WBC Alba White 10-21days Mucus GILBERT T. SALACUP RN,MSN
  103. 103. Perineum E - dema R - edness E - cchymosis D - ischarge A – pproximation Fully saturated – 30 – 40 cc Weighing – 1 cc = 1 gram Common Board Question GILBERT T. SALACUP RN,MSN
  104. 104. Nursing Consideration during RecoveryF - lat on bed to prevent dizzinessI - f with Chills  give blanket due to dehydrationN - ourishment (progression of meal)  Clear liquids – gatorade, ginger juice, gelatins  Full liquid – milk, ice cream  Soft diet  Regular dietC - heck VS/ PainBonding – interaction between mother and newborn Strict – 24 hours with mother Partial – morning with mother, night nursery GILBERT T. SALACUP RN,MSN
  105. 105. Complications of LaborDystocia – difficult labor related to:Mechanical factor – due to uterine inertia – sluggishness of contraction4. Hypertonic or primary uterine inertia- intense excessive contractions resulting to ineffective pushing MD administer sedative valium,/diazepam – muscle relaxant7. Hypotonic – secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin. Prolonged labor – normal length of labor in primi 14 – 20 hrs Multi 10 -14 hrs > 14 hrs in multi & > 20 hrs in primimaternal effect – exhaustion.Fetal effect – fetal distress, caput succedaneum or cephal hematomansg care: monitor contractions and FHR GILBERT T. SALACUP RN,MSN
  106. 106. Precipitate Laborlabor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.Earliest sign: tachycardia & restlessnessLate sign: hypotensionBest Nursing dx: fluid volume deficitPost of mom – modified trendelenbergIV – fast drip due fluid volume def Signs of Hypovolemic Shock: Hypo-tension Tachy-cardia Tachy-pnea Co-ld clammy skinInversion of the uterus – situation uterus is inside out.MD will push uterus back inside or not hysterectomy. Factors leading to inversion of uterus S -hort cord H -urrying of placental delivery I -neffective fundal pressure GILBERT T. SALACUP RN,MSN
  107. 107. Uterine RuptureCauses:1.)Previous classical CS2.)Large baby3.) Improper use of oxytocin (IV drip)Sx: sudden pain, profuse bleeding , hypovolemic shock - TAHBSOBANDL’S pathologic ring – suprapubic depression, sign of impending uterine rupture Amniotic Fluid Embolism or placental embolism– amniotic fluid or fragments of placenta enters natural circulation resulting to embolismSx:dyspnea, chest pain & frothy sputum Prepare: suctioning end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body – eyes, nose, etc. GILBERT T. SALACUP RN,MSN
  108. 108. Preterm Labor – labor 20 – 37 weeks) ( abortion <20 weeks)Sx: 1. premature contractions q 10 min 2. effacement of 60 – 80% 3. dilation 2-3 cm Home Mgt:1. complete bed rest2. avoid sex3. empty bladder4. drink 3 -4 glasses of water – full bladder inhibits contractions5. consult MD if symptoms persist Hosp: If cervix is closed 2 – 3 cm, dilation saved by administer Tocolytic agents-YUTOPAR- Yutopar Hcl 150mg incorporated 500cc Dextrose piggyback. Monitor: FHT > 180 bpm Maternal BP - <90/60Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IVTocolyticTerbuthaline (Bricanyl or Brethine) – sustained tachycardiaAntidote – propranolol or inderal - beta-blockerIf cervix is open – MD – steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDSPreterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.  GILBERT T. SALACUP RN,MSN
  109. 109. POSTPARTAL PERIODPuerperium – 5th stage of labor, 1st 6 weeks post partum Characterize by involutionInvolution - return to the normal stage of reproductive organ after pregnancy Hyperfibrinogenia- prone to thrombus formation- early ambulationUterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10th day – no longer palpable due behind symphisis pubisPuerperal sepsis - 3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a medium for bacterial growth- D&CAfter, birth pain:1. position prone2. cold compress – to prevent bleeding3. mefenamic acidLochia- bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.Urinary tract:Bladder – freq in urination after delivery- urinary retention with overflowColon:Constipation – due NPO, fear of bearing downPerineal area – painful – episiotomy site – sims pos, cold compress for immediate pain after 24 hrs, hot sitz bath, not compresssex- when perineum has healed GILBERT T. SALACUP RN,MSN
  110. 110. Post partum Psychological response according to Reva Rubin Phase Characteristic Nursing CareTaking In Reflection/Dependent Phase •Encourage to tell story 2-3 days about childbirth experience Client is Passive •Encourage restTaking Hold Dependent to Independent Phase •Positive reinfircement Start to make decision Emphasize on the care of the Active new born 4-5 days •Initiate Family Planning MethodLetting Go Independent phase Encourage Prenatal Love Redefining the New Role and positive Family relationShip GILBERT T. SALACUP RN,MSN
  111. 111. PreventComplicationsGILBERT T. SALACUP RN,MSN
  112. 112. Hemorrhage – bleeding of > 500cc CS – 600 – 800 cc normal NSD 500 ccEarly postpartum hemorrhage– bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding – uterine atony. Complications: hypovolemic shock.Mgt: Massage uterus until contracted Cold compress Modified trendelenberg IV fast drip/ oxytocin IV drip1st degree laceration – affects vaginal skin & mucus membrane.2nd degree – 1st degree + muscles of vagina3rd degree – 2nd degree + external sphincter of rectum4th degree – 3rd degree + mucus membrane of rectum  GILBERT T. SALACUP RN,MSN 
  113. 113. Breast feedingpost pit gland will release oxytocin so uterus will contract.Well contracted uterus + bleeding = lacerationassess perineum for laceration mgt episiorapy DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate. bleeding to any part of body hysterectomy if with abruption placenta mgt: BT- cryoprecipitate or fresh frozen plasma GILBERT T. SALACUP RN,MSN
  114. 114. Late Postpartum hemorrhage– bleeding after 24 hrs – retained placental fragmentsMgt: D&C or manual extraction of fragments & massaging of uterusPlancenta Acreta – attached placenta to myometrium.Plancenta Increta – deeper attachment of placenta to myometrium hysterectomyPlancenta Percreta – invasion of placenta to perimetrium Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum. too much manipulation large baby pudendal anesthesiaMgt:  cold compress every 30 minutes with rest period of 30 minutes for 24 hrs  shave  incision on site, scraping & suturing GILBERT T. SALACUP RN,MSN
  115. 115. Uterine Atony boggy fundus profuse bleedingInterventions  massage the uterus  cold compress  modified trendelenburg  fast drip IV  breastfeeding – to release oxytocinInfection-Sources of infection1.)endogenous – from within body2.) exogenous – from outside anaerobic streptococci – most common - from members health team unhealthy sexual practicesGeneral signs of inflammation:  Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)  purulent discharges  fever   GILBERT T. SALACUP RN,MSN
  116. 116. Gen mgt:Supportive Care– CBR, hydration, TSB, cold compress, paracetamol, VITC culture & sensitivity – for antibiotic Inflammation of perineumsee general signs of inflammation 2 to 3 stitches dislocated with purulent dischargeMgt: Removal of sutures & drainage, saline, between & resulting. GILBERT T. SALACUP RN,MSN
  117. 117. Family PlanningGILBERT T. SALACUP RN,MSN
  118. 118. Motivate the use of Family Planning determine one’s own beliefs 1st never advice a permanent method of planning method of choice is an individuals choice.Natural Method – accepted by the Catholic Church 1. Rhythm/Calendar/Ogino Knause Formulao Couple abstains on days that the woman is fertileo Menstrual cycles are observed and charted for 12 months Standard Formula:first day of the beginning of one cycle to the first day of the next cycleshortest cycle = minus 18 longest cycle = minus 11Example: shortest cycle = 28 longest cycle = 35Shortest cycle: 28 days – 18 = 10Longest cycle: 35 days – 11 = 24Fertile pd: 10th to 24th day of cycle = No sexual intercourse  GILBERT T. SALACUP RN,MSN
  119. 119. Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen) clear, watery, stretchable, elastic – long spinnbarkeit Sexual Intercourse may be resumed after 3 – 4 daysBasal Body Temperature 13th day temp goes down before ovulation – no sex get before arising in bedLAM – lactation amenorrheal method–hormone that inhibits ovulation is prolactin. breast feeding- menstruation will come out 4 – 6 months bottle fed 2 – 3 months disadvantage of lam – might get pregnantSymptothermal – combination of BBT & cervical. Best method Resume Sexual intercourse after 3 – 4 days Recommended observation of BBT is 6 menstrual cycle to establish pattern of fluctuationsCoitus Interuptus – withdrawal - least effective methodCoitus Reservatus - sex w/o ejaculationCoitus interfemora - between femor GILBERT T. SALACUP RN,MSN
  120. 120. Artificial Method ContraindicationsOral Contraceptive Pills Hi-gh serum of level of liver enzymes 99.9% effective. Hi-gh blood pressure/DM Waiting time to become pregnant- 3 months. Consult OB-6mos. Hi –story of CVA contains estrogen that inhibits FSH and progesterone that inhibit LH D- VT/Thrombophlebitis 99.9% effective Wo- men who smoke 21 day feel on the 5th day of mense T –hirty five y/o/ extreme Obese start taking 28 day – 1st day of mense if forgotten, take 2 tablets the Immediate Discontinue following day A-bdominal pain adverse effect : breakthrough bleeding Side effect: C-hest painMO- nilial Vaginal Infection H-eadacheMi - ld HPN AND DepressionHe – adache E-ye problemNa - usea /wt, gain S-evere leg cramp GILBERT T. SALACUP RN,MSNB – reast tenderness
  121. 121. 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 GILBERT T. SALACUP RN,MSN
  122. 122. Mechanical DeviceIntrauterine Device (IUD) Action: prevents implantation – affects motility of sperm & ovum right time to insert is after delivery or during menstruation Primary indication for use of IUD Parity or # of children, if 1 kid only don’t use IUDHT:  Check for string daily  Monthly checkup  Regular pap smearG notes: Most common complications: excessive menstrual flow and expulsion of the deviceothers:S - trings lost, shorter or longerP eriod late (pregnancy suspected) Abnormal spotting or bleedingA bdominal pain or pain with intercourseI nfection (abnormal vaginal discharge)N ot feeling well, fever, chills Uterine inflammation, uterine perforation, ectopic pregnancy GILBERT T. SALACUP RN,MSN
  123. 123. 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 maleAdv; gives highest protection against STDDisadvantage: it lessen sexual satisfaction Diaphragm– rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. Reusable Ht: proper hygiene check for holes before use: must stay in place 6 – 8 hrs after sex must be refitted especially if without wt change 15 lbs Spermicide – chem. Barrier ex. Foam (most effective), jellies, creams S/effect: Toxic shock syndrome Alerts: Should be kept in place for about 6 – 8 hours GILBERT T. SALACUP RN,MSN
  124. 124. 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 GILBERT T. SALACUP RN,MSN
  125. 125. SURGICAL METHODBilateral tubal Ligation @ isthmus 20% probability of reversalVasectomy Vas deferens is cut More than 30 x ejaculation or 0 sperm count or 2 x negative sperm count before it could be consider safe sex  GILBERT T. SALACUP RN,MSN
  126. 126. High Risk PregnancyHemorrhagic Disorders General Management CBR Avoid sex Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc) Ultrasound to determine integrity of sac Signs of Hypovolemic shock Save discharges – for histopathology – to determine if product of conception has been expelled or not GILBERT T. SALACUP RN,MSN
  127. 127. First Trimester Bleeding Abortion – termination of labor before age of viability SPONTANEOUS AKA miscarriage Causes Chromosomal aberrations due to advanced maternal age Blighted ovum and Plasma germ defect  Natures way of expelling defective babies Classifications : Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is closed and can be saved. Inevitable - can NOT be prevented moderate bleeding, cramping, tissue protrudes from the cervix and the cervix is open.Types :Complete - all products of conception are expelled. Mgt : emotional supportIncomplete - placenta and membranes retained. Mgt : D&CMissed abortion – Fetus die in uterus, but it is not expelledHabitual abortion – 3 – 6 abortions INDUCED Therapeutic abortion  principle of 2 fold effect GILBERT T. SALACUP RN,MSN
  128. 128. Ectopic Pregnancy occurs when gestation is located outside the uterine cavity. common site: tubal or ampular Dangerous site - interstitial Unruptured Tubal rupture•Missed period•Abdominal pain w/in 3 -5 wks of missed •Su-dden , sharp, severe pain. Unilateral radiating to shoulder. period (maybe generalized or one sided)•Scant, dark brown, vaginal bleeding •Shou-lder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve) + Cullen’s Sign – bluish tinged umbilicus –Nursing care: signifies intra peritoneal bleedingMo -nitor for vaginal bleeding •Sy- ncope (fainting)V -ital signs Mgt: Surgery depending on sideM-onitor I & O O - vary: oophrectomyA - dminister IV fluids U - terus : hysterectomy GILBERT T. SALACUP RN,MSN
  129. 129. Second trimester bleeding Hydatidiform Mole “bunch orgrapes”orgestational trophoblasticdse– with fertilization. Progressive degeneration of chorionic villi. Recurs.- gestational anomaly of the placenta consisting of a bunch of clear vesicles.- This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.Use: methotrexate to prevent choriocarcinomaAssessment:Early signs-vesicles passed thru the vaginaHyperemesis gravidarium increase HCGFundal heightVaginal bleeding( scant or profuse) GILBERT T. SALACUP RN,MSN
  130. 130. Early in pregnancy High levels of HCG Preeclampsia at about 12 weeksLate signs hypertension before 20th week Vesicles look like a “ snowstorm” on sonogram Anemia, Abdominal crampingSerious complications :hyperthyroidism,Pulmonary embolusNursing care: Prepare D&C Do not give oxytoxic drugs Teachings:  Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma  Avoid pregnancy for at least one year GILBERT T. SALACUP RN,MSN
  131. 131. Third Trimester Bleeding “Placenta Anomalies” Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta. candidate for CSSx: Prank, Bright red, Painless bleeding Dx: UltrasoundAvoid: sex, IE, enema – may lead to sudden fetal blood loss Double set up: delivery room may be converted to ORAssessment:Engagement (usually has not occurred) Fetal distress, Presentation ( usually abnormal) Surgeon – in charge of sign consent, RN as witness MD explain to patient complication: sudden fetal blood loss Nursing Care  NPO - Bed rest  Prepare to induce labor if cervix is ripe  Administer IV GILBERT T. SALACUP RN,MSN
  133. 133. Abruptio Placentapremature separation of the placenta form the implantation site. It occurs after the twentieth week of pregnancy.Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.Assessment: Concealed bleeding (retroplacental) Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage. Severe abdominal pain Dropping coagulation factor (a potential for DIC) Complications: Sudden fetal blood loss placenta previa & vasa previaNursing Care: Infuse IV, prepare to administer blood Type and crossmatch Monitor FHR Insert Foley Measure blood loss; count pads Report s/sx of DIC Monitor v/s for shock Strict I&O GILBERT T. SALACUP RN,MSN