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OB Notes

  1. 1. MATERNAL/OB NOTES Human Sexuality A. Concepts 1. A person’s sexuality encompasses the complex behaviors, attitudes emotions and preferences that are related to sexual self and eroticism. 2. Sex – basic and dynamic aspect of life 3. During reproductive years, the nurse performs as resource person on human sexuality. B. Definitions related to sexuality: Gender identity – sense of femininity or masculinity 2-4 yrs/3 yrs gender identity develops. Role identity – attitudes, behaviors and attributes that differentiate roles Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse. Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change. - developed at the moment of conception. II. Sexual Anatomy and Physiology A. Female Reproductive System 1. External value or pretender a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis. Stages of Pubic Hair Development Tannerscale tool - used to determine sexual maturity rating. Stage 1 – Pre-adolescence. No pubic hair. Fine body hair only Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly hair at pubis symphysis Stage 3 occurs between ages 12 and 13 – darker & curlier at labia Stage 4 – occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh. Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh . b. Labia Majora - large lips longitudinal fold, extends symphisis pubis to perineum c. Labia Minora – 2 sensitive structures clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of sexual arousal (Greek-key) fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during delivery. Site – episiotomy. d. Vestibule – an almond shaped area that contains the hymen, vaginal orifice and bartholene’s glands. 1. Urinary Meatus – small opening of urethra, serves for urination 2. Skenes glands/or paraurethral gland – mucus secreting subs for lubrication 3. hymen – covers vaginal orifice, membranous tissue 4. vaginal orifice – external opening of vagina 5. bartholene’s glands- paravaginal gland or vulvo vaginal gland -2 small mucus secreting subs – secrets alkaline subs. Alkaline – neutralizes acidity of vagina Ph of vagina - acidic Doderleins bacillus – responsible for acidity of vagina Carumculae mystiformes-healing of torn hymen e. Perineum – muscular structure – loc – lower vagina & anus Internal: A. vagina – female organ of copulation, passageway of mens & fetus, 3 – 4inches or 8 – 10 cm long, dilated canal Rugae – permits stretching without tearing B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights. 1
  2. 2. Size- 1x2x3 Shape: nonpregnant pear shaped / pregnant - ovoid Weight - nonpregnant – 50 -60 kg- pregnant – 1,000g Pregnant/ Involution of uterus: 4th stage of labor - 1000g 2 weeks after delivery - 500g 3 weeks after delivery - 300 g 5-6 weeks after delivery - returns to original, state 50 – 60 Three parts of the uterus 1. fundus - upper cylindrical layer 2. corpus/body - upper triangular layer 3. cervix - lower cylindrical layer * Isthmus lower uterine segment during pregnancy Cornua-junction between fundus & interstitial Muscular compositions: there are three main muscle layers which make expansion possible in every direction. 1. Endometrium- inside uterus, lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs during menstruation. Decidua- thick layer. Endometriosis-proliferation of endometrial lining outside uterus. Common site: ovary. S/sx: dysmennorhea, low back pain. Dx: biopsy, laparoscopy Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit ovulation 2. Lupreulide (Lupron) –inhibit FSH/LH production 2. Myometrium – largest part of the uterus, muscle layer for delivery process • Its smooth muscles are considered to be the living ligature of the body. - Power of labor, resp- contraction of the uterus 3. Perimetrium – protects entire uterus C. ovaries – 2 female sex glands, almond shaped. Ext- vestibule int – ovaries Function: 1. ovulation 2. Production of hormones d. Fallopian tubes – 2-3 inches long that serves as a passageway of the sperm from the uterus to the ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus. 4 significant segments 1. Infundibulum – distal part of FT, trumpet or funnel shaped, swollen at ovulation 2. Ampulla – outer 3rd or 2nd half, site of fertilization 3. Isthmus – site of sterilization – bilateral tubal ligation 4. Interstitial – site of ectopic pregnancy – most dangerous B. Male Reproductive System 1. External penis – the male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female – the glands penis. 3 Cylindrical Layers 2 corpora cavernosa 1 corpus spongiosum Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which contains a testes. - cooling mechanism of testes - < 2 degrees C than body temp. - Leydig cell – release testosterone 2
  3. 3. 2. Internal The Process of Spermatogenesis – maturation of sperm Testes – 900 coiled (½ meter long Blank! Can’t erase! at age 13 onwards) (Seminiferous tubules) Hypothalamus Epididymis – 6 meters coiled tubules site for maturation of sperm GnRH Vas Deferens – conduit for spermatozoa or pathway of sperm Ant Pit Gland Seminal vesicle – secretes: 1.) Fructose – glucose has FSH LF nutritional value. 2.) Prostaglandin – causes reverse contraction of uterus Ejaculatory duct – conduit of semen Fx: Fx: Hormones Sperm for Maturation Testosterone Production Prostate gland- secrets alkaline substance Cowpers gland secrets alkaline substance Urethra Male and Female homologues Male Female Penile glans Clitoral glans Penile shaft Clitorial shaft Testes ovaries Prostate Skene’s gands Cowper’s Glands Bartholin's glands Scrotum Labia Majora 3
  4. 4. III. Basic Knowledge on Genetics and Obstetrics 1. DNA – carries genetic code 2. Chromosomes – threadlike strands composed of hereditary material – DNA 3. Normal amount of ejaculated sperm 3 – 5 cc., 1 tsp 4. Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation 5. Sperm is viable within 48 – 72 hrs, 2-3 days 6. 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 7. Age of Reproductivity – 15 – 44yo 8. Menstruation- Menstrual Cycle – beginning of mens to beginning of next mens Average Menstrual Cycle – 28 days Average Menstrual Period - 3 – 5 days Normal Blood loss – 50cc or ¼ cup Related terminologies: Menarche – 1st mens Dysmenorrhea – painful mens Metrorrhagia – bleeding between mens Menorhagia – excessive during mens Amenorrhea – absence of mens Menopause – cessation of mens/ average : 51 years old 9. Functions of Estrogen and Progestin * Estrogen “Hormone of the Woman” – Primary function: development secondary sexual characteristic female. Others: 1. inhibit production of FSH ( maturation of ovum) 2. hypertrophy of myometrium 3. Spinnbarkeit & Ferning ( billings method/ cervical) 4. development ductile structure of breast 5. increase osteoblast activities of long bones 6. increase in height in female 7. causes early closure of epiphysis of long bones 8. causes sodium retention 9. increase sexual desire *Progestin “ 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 10. Menstrual Cycle 4 phases of Menstrual Cycle 1. Phases of Menstrual Cycle: 1. Proliferative 2. Secretory 3. Ischemic 4. Menses Parts of body responsible for mens: 1. hypothalamus 2. anterior pituitary gland – master clock of body 4
  5. 5. 3. ovaries 4. uterus Initial phase – 3rd day – decreased estrogen 13th day – peak estrogen, decrease progesterone 14th day – Increase estrogen, increase progesterone 15th day – Decrease estrogen, increase progesterone I. On the initial 3rd phase of menstruation , the estrogen level is decreased, this level stimulates the hypothalamus to release GnRH or FSHRF II. GnRH/FSHRF – stimulates the anterior pituitary gland to release FSH Functions of FSH: 1. Stimulate ovaries to release estrogen 2. Facilitate growth primary follicle to become graffian follicle (secrets large amt estrogen & contains mature ovum.) III. Proliferative Phase – proliferation of tissue or follicular phase, post mens phase. Pre-ovularoty. -phase of increase estrogen. Follicular Phase – causing irregularities of mens Postmenstrual Phase Preovulatory Phase – phase increase estrogen IV. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these stimulates the hypothalamus to release GnRF on LHRF 1.) Mittelschmerz – slight abdominal pain on L or RQ of abdomen, marks ovulation day. 2.) Change in BBT, mood swing V. GnRF/LHRF stimulates the ant pit gland to release LH. Functions of LH: 1. (13th day-decreased progesterone) LH stimulates ovaries to release progesterone 2. hormone for ovulation VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of ovulation. VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus luteum (secrets large amount of progesterone) VIII. Secretory phase- Lutheal Phase Postovulatory Phase Increased progesterone Premenstrual Phase IX. 24th day if no fertilization, corpus luteum degenerate ( whitish – corpus albicans) X. 28th day – if no sperm in ovum – endometrium begins to slough off to begin mens Fornix- where sperm is deposited Sperm- small head, long tail, pearly white Phonones-vibration of head of sperm to determine location of ovum Sperm should penetrate corona radiata and zona pellocida. Capacitation- ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona pellocida. 11. Stages of Sexual Responses (EPOR) Initial responses: Vasocongestion – congestion of blood vessels Myotonia – increase muscle tension 1. Excitement Phase – (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) – erotic stimuli cause increase sexual tension, lasts minutes to hours. 2. Plateau Phase – (accelerated V/S) – increasing & sustained tension nearing orgasm. Lasts 30 seconds – 3 minutes. 5
  6. 6. 3. Orgasm – (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. 4. Resolution – (v/s return to normal, genitals return to pre-excitement phase) Refractory Period – the only period present in males, wherein he cannot be restimulated for about 10-15 minutes A. Fertilization B. Stages of Fetal Growth and Development 3-4 days travel of zygote – mitotic cell division begins *Pre-embryonic Stage a. Zygote- fertilized ovum. Lifespan of zygote – from fertilization to 2 months b. Morula – mulberry-like ball with 16 – 50 cells, 4 days free floating & multiplication c. Blastocyst – enlarging cells that forms a cavity that later becomes the embryo. Blastocyst – covering of blastocys that later becomes placenta & trophoblast d. Implantation/ Nidation- occurs after fertilization 7 – 10 days. Fetus- 2 months to birth. placenta previa – implantation at low side of uterus Signs of implantation: 1. slight pain 2. slight vaginal spotting - if with fertilization – corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed. 3 processes of Implantation 1. Apposition 2. Adhesion 3. Invasion C. Decidua – thickened endometrium ( Latin – falling off) * Basalis (base) part of endometrium located under fetus where placenta is delivered * Capsularies – encapsulate the fetus * Vera – remaining portion of endometrium. C. Chorionic Villi- 10 – 11th day, finger life projections 3 vessels= A – unoxygenated blood V – O2 blood A – unoxygenated blood Wharton’s jelly – protects cord Chorionic villi sampling (CVS) – removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes. E. Cytotrophoblast – inner layer or langhans layer – protects fetus against syphilis 24 wks/6 months – life span of langhans layer increase. Before 24 weeks critical, might get infected syphilis F. Synsitiotrophoblast – synsitial layer – responsible production of hormone 1. Amnion – inner most layer a. Umbilical Cord- FUNIS, whitish grey, 15 – 55cm, 20 – 21”. Short cord: abruptio placenta or inverted uterus. Long cord:cord coil or cord prolapse b. Amniotic Fluid – bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline. *Function of Amniotic Fluid: 1. cushions fetus against sudden blows or trauma 2. facilitates musculo-skeletal development 3. maintains temp 6
  7. 7. 4. prevent cord compression 5. help in delivery process normal amt of amniotic fluid – 500 to 1000cc polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid oligohydramnios- decrease amt of fluid – kidney disease Diagnostic Tests for Amniotic Fluid A. Amniocentesis empty bladder before performing the procedure. Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for: 1. Genetic screening- maternal serum alpha feto-protein test (MSAFP) – 1st trimester 2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity – 3rd trimester Testing time – 36 weeks decreased MSAFP= down syndrome increase MSAFP = spina bifida or open neural tube defect Common complication of amniocenthesis – infection Dangerous complications – spontaneous abortion 3rd trimester- pre term labor Important factor to consider for amniocentesis- needle insertion site Aspiration of yellowish amniotic fluid – jaundice baby Greenish – meconium A. Amnioscopy – direct visualization or exam to an intact fetal membrane. B. Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid) C. Nitrazine Paper Test – diff amniotic fluid & urine. Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid. 1. Chorion – where placenta is developed Lecithin Sphingomyelin L/S Ratio- 2:1 signifies fetal lung maturity not capable for RDS Shake test – amniotic + saline & shake Foam test Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity a. Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis. Size: 500g or ½ kg -1 inch thick & 8” diameter Functions of Placenta: 1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion 2. GIT – transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic 3. Excretory System- artery - carries waste products. Liver of mom detoxifies fetus. 4. Circulating system – achieved by selective osmosis 5. Endocrine System – produces hormones • Human Chorionic Gonadrophin – maintains corpus luteum alive. 7
  8. 8. • 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 6. It serves as a protective barrier against some microorganisms – HIV,HBV Fetal Stage “ Fetal Growth and Development” Entire pregnancy days – 266 – 280 days 37 – 42 weeks Differentiation of Primary Germ layers * Endoderm 1st week endoderm – primary germ layer Thyroid – for basal metabolism Parathyroid - for calcium Thymus – development of immunity Liver – lining of upper RT & GIT * Mesoderm – development of heart, musculoskeletal system, kidneys and repro organ * Ectoderm – development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth First trimester: 1st month - Brain & heart development GIT& resp Tract – remains as single tube 1. Fetal heart tone begins – heart is the oldest part of the body 2. CNS develops – dizziness of mom due to hypoglycemic effect Food of brain – glucose complex CHO – pregnant womans food (potato) Second Month 1. All vital organs formed, placenta developed 2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month 3. Sex organ formed 4. Meconium is formed Third Month 1. Kidneys functional 2. Buds of milk teeth appear 3. Fetal heart tone heard – Doppler – 10 – 12 weeks 4. Sex is distinguishable Second Trimester: FOCUS – length of fetus Fourth Month 1. lanugo begins to appear 2. fetal heart tone heard fetoscope, 18 – 20 weeks 3. buds of permanent teeth appear Fifth Month 1. lanugo covers body 2. actively swallows amniotic fluid 3. 19 – 25 cm fetus, 4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks – multi 5. fetal heart tone heard with or without instrument Sixth Month 1. eyelids open 2. wrinkled skin 3. vernix caseosa present 8
  9. 9. Third trimester: Period of most rapid growth. FOCUS: weight of fetus Seventh Month – development of surfactant – lecithin Eighth Month 1. lanugo begin to disappear 2. sub Q fats deposit 3. Nails extend to fingers Ninth Month 1. lanugo & vernix caseosa completely disappear 2. Amniotic fluid decreases Tenth Month – bone ossification of fetal skull Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus A. Drugs: Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing & deafness Tetracycline – staining tooth enamel, inhibit growth of long bone Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundice Iodides – enlargement of thyroid or goiter Thalidomides – Amelia or pocomelia, absence of extremities Steroids – cleft lip or palate Lithium – congenital malformation B. Alcohol – lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by microcephaly C. Smoking – low birth rate D. Caffeine – low birth rate E. Cocaine – low birth rate, abruption placenta TORCH (Teratogenic) Infections – viruses CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus. T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat O – others. Hepa A or infectious heap – oral/ fecal (hand washing) Hepa B, HIV – blood & body fluids Syphilis R – rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10 <1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’t get pregnant for 3 months. Vaccine is teratogenic C – cytomegalo virus H – herpes simplex virus I. Physiological Adaptation of the Mother to Pregnancy A. Systemic Changes 1. 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 women Normal Values 9
  10. 10. Hct 32 – 42% Hgb 10.5 – 14g/dL Criteria 1st and 3rd trimester.- pathologic anemia if lower HCT should not be 33%, Hgb should not be < 11g/dL 2nd trimester – Hct should not <32% Hgb Shdn't < 10.5% pathologic anemia if lower 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 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 (ferrous sulfate 0.3 g. 3 times a 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 • Iron is better absorbed when taken with foods high in Vit 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 – lower extremities due venous return is constricted due to large belly, elevate legs above hip level. Varicosities – pressure of uterus - use support stockings, avoid wearing knee high socks - use elastic bandage – lower to upper - Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position – side lying with pillow under hips or modified knee chest position Thrombophlebitis – presence of thrombus at inflamed blood vessel - pregnant mom hyperfibrinogenemia - increase fibrinogen - increase clotting factor - thrombus formation candidate Outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion Milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens Mgt: 1.) Bed rest 2.) Never massage 3.) Assess + Homan sign once only might dislodge thrombus 4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute) 5.) Monitor APTT antidote for Heparin toxicity, protamine sulfate 6.) Avoid aspirin! Might aggravate bleeding. 2. Respiratory system – common problem SOB due to enlarged uterus & increase O2 demand Position- lateral expansion of lungs or side lying position. 10
  11. 11. 3. Gastrointestinal – 1st trimester change • Morning 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&O constipation – progesterone resp for constipation. Increase fluid intake, increase fiber diet - fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha. Except guava – has pectin that’s constipating – veg – petchy, malungay. - exercise -mineral oil – excretion of fat soluble vitamins * Flatulence – avoid gas forming food – cabbage * Heartburn – or pyrosis – reflux of stomach content to esophagus - small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical increase salivation – ptyalsim – mgt mouthwash *Hemorrhoids – pressure of gravid uterus. Mgt; hot sitz bath for comfort 4. Urinary System – frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos – mgt for nocturia Acetyace test – albumin in urine Benedicts test – sugar in urine 5. Musculoskeletal Lordosis – pride of pregnancy Waddling Gait – awkward walking due to relaxation – causes softening of joints & bones Prone to accidental falls – wear low heeled shoes Leg 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 B. Local Changes Local change: Vagina: V – Chadwick’s sign – blue violet discoloration of vagina C – Goodel's sign – change of consistency of cervix I – Hegar's – change of consistency of isthmus (lower uterine segment) LEUKORRHEA – whitish gray, mousy odor discharge ESTROGEN – hormone, resp for leucorrhea OPERCULUM – mucus plug to seal out bacteria. PROGESTERONE – hormone responsible for operculum PREGNANT – acidic to alkaline change to protect bacterial growth (vaginitis) Problems Related to the Change of Vaginal Environment: a. Vaginitits – trichomonas vaginalis due to alkaline environment of vagina of pregnant mom Flagellated protozoa – wants alkaline S&Sx: Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema Mgt: 11
  12. 12. FLAGYL – (metronidazole – antiprotozoa). Carcinogenic drug so don’t give at 1st trimester 1. treat dad also to prevent reinfection 2. no alcohol – has antibuse effect VAGINAL DOUCHE – IQ H2O : 1 tbsp white vinegar b. Moniliasis or candidiasis due to candida albecans, fungal infection. Color – white cheese like patches adheres to walls of vagina. Signs & Symptoms: Management – antifungal – Nistatin, genshan violet, cotrimaxole, canesten Gonorrhea -Thick purulent discharge Vaginal warts- condifoma acuminata due to papilloma virus Mgt: cauterization 2. Abdominal Changes – striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue – avoid scratching, use coconut oil, umbilicus is protruding 3. Skin Changes – brown pigmentation nose chin, cheeks – chloasma melasma due to increased melanocytes. Brown pinkish line- linea nigra- symphisis pubis to umbilicus 4. Breast Changes – increase hormones, color of areola & nipple pre colostrums present by 6 weeks, colostrums at 3rd trimester Breast self exam- 7 days after mens –– supine with pillow at back quadrant B – upper outer – common site of cancer Test to determine breast cancer: 1. mammography – 35 to 49 yrs once every 1 to 2 yrs 50 yrs and above – 1 x a yr 6. Ovaries – rested during pregnancy 7. Signs & symptoms of Pregnancy A. Presumptive – s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . Subjective B. Probable – signs observed by the members of health team. Objective C. Positive Signs – undeniable signs confirmed by the use of instrument. Ballotment sign of myoma * + HCG – sign of H mole - trans vaginal ultrasound. Empty bladder - ultrasound – full bladder placental grading – rating/grade o – immature 1 – slightly mature 2 – moderately mature 3 – placental maturity What is deposited in placenta which signify maturity - there is calcium Presumptive Probable Positive Breast changes Goodel's- change of consistency of cervix Ultrasound evidence Urinary freq Chadwick’s- blue violet discoloration of vagina (sonogram) full bladder Fatigue Hegar's- change of consistency of isthmus Amenorrhea Elevated BBT – due to increased progesterone Fetal heart tone Morning sickness Positive HCG or (+)preg test Fetal movement 12
  13. 13. Enlarged uterus Fetal outline Ballottement – bouncing of fetus when lower uterine is tapped Fetal parts palpable Cloasma sharply Linea negra Enlarged abdomen Increased skin pigmentation Braxton Hicks contractions – painless irregular contractions Striae gravidarium Quickening VI. Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory) First Trimester: No tanginal signs & sx, surprise, ambivalence, denial – sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy Focus: bodily changes of preg, nutrition Second Trimester – 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: - mom has personal identification on appearance of baby Development 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 Lamaze classes VII. Pre-Natal Visit: 1. Frequency of Visit: 1st 7 months – 1x a month 8 – 9 months – 2 x a month 10 – once a week post term 2 x a week 2. Personal data – name, age (high risk < 18 & >35 yrs old) record to determine high risk – HBMR. Home base mom’s record. Sex ( pseudocyesis or false pregnancy on men & women) Couvade syndrome – dad experiences what mom goes through – lihi) Address, civil status, religion, culture & beliefs with respect, non judgmental Occupation – financial condition or occupational hazards, education background – level knowledge 3. Diagnosis of Pregnancy 1.) urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6 weeks after LMP- best to get urine exam. 2.) Elisa test – test for preg detects beta subunit of HCG as early as 7 – 10days 3.) Home preg kit – do it yourself 4. Baseline Data: V/S esp. BP, monitor wt. (increase wt – 1st sign preeclampsia) Weight Monitoring First Trimester: Normal Weight gain 1.5 – 3 lbs (.5 – 1lb/month) Second trimester: normal weight gain 10 – 12 lbs (4 lbs/month) (1 lb/wk) Third trimester: normal weight gain 10 – 12 lbs (4 lbs/ month) ( 1lb/wk) Minimum wt gain – 20 – 25 lbs Optimal wt gain – 25 – 35 lbs 5. Obstetrical Data: nullipara – no pregnancy a. Gravida- # of pregnancy b. Para - # of viable pregnancy Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age. age of viability - 20 – 24 wks Term 37 – 42 wks, Preterm -20 – 37 weeks 13
  14. 14. abortion <20 weeks Sample Cases: 1 – abortion GTPAL 1 – 2nd mo 2 0 01 0 G–2 P–0 1 – 40th AOG GT P A L 1 – 36th AOG 612 2 4 2 – misc 1 – twins 35 AOG 1 – 4th month G6 P3 1 – 39th week 1 – miscarriage GP GTPAL 1 – stillbirth 33 AOG (considered as para) 4 2 4 11 1 1 1 – preg 3rd wk 1 – 33 P 1 41st L 1 – abort A 1 – still 39 GP GTPAL 1 triplet 32 6 4 6 2 2 15 1 4th mon c. Important Estimates: 1. Nagele’s Rule – use to determine expected date of delivery Get LMP -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar M D Y +9 +7 no year LMP Jan 25, 04 +9 +7 10 / 32 / 04 - 1 add 1 month to month 11/31/04 EDD 2. McDonald’s Rule – to determine age of gestation IN WEEKS FUNDIC HT X 7/8=AOG in WK Fundic Ht X 7 = AOG in weeks 8 Fr sypmhisis pubis to fundus 24 X 7 =21 wks 8 3. Bartholomew’s Rule – to determine age of gestation by proper location of fundus at abdominal cavity. 3 months – above sym pub 5 months – level of umbilicus 9 months – below zyphoid 10 months – level of 8 months due to lightening 4. Haases rule – to determine length of the fetus in cm. Formula: 1st ½ of preg , square @ month 2nd ½ of preg, x @ month by 5 3mos x 3 = 9cm 4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg 5 x 5 = 25 cm 6 x 5 = 30 cm 7 x 5 = 35 cm 2nd ½ of preg 14
  15. 15. 8 x 5 = 40 cm 9 x 5 = 45 cm d. tetanus immunizations – prevents tetanus neonatum -mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3 TT1 – any time during pregnancy TT2 – 4 wks after TT1 – 3 yrs protection TT3 – 6 months after TT2 – 5 yrs protection TT4 – 1 yr after TT3 – 10 yrs protection TT5 – yr after TT4 – lifetime protection 5. Physical Examination: A. Examine teeth: sign of infection Danger signs of Pregnancy C - chills/ fever - infection Cerebral disturbances ( headache – preeclampsia) A – abdominal pain ( epigastric pain – aura of impending convulsions B – boardlike abdomen – abruption placenta Increase BP – HPN Blurred vision – preeclampsia Bleeding – 1st trimester, abortion, ectopic pre/2nd – H mole, incompetent cervix 3rd – placental anomalies S – sudden gush of fluid – PROM (premature rupture of membrane) prone to inf. E – edema to upper ext. (preeclampsia) 6. Pelvic Examination – internal exam 1. empty bladder 2. universal precaution EXT OS of cervix – site for getting specimen Site for cervical cancer Pap Smear – cervical cancer - composed of squamous columnar tissue Result: Class I - normal Class IIA – acytology but no evidence of malignancy B – suggestive of infl. Class III – cytology suggestive of malignancy Class IV – cytology strongly suggestive of malignancy Class V – cytology conclusive of malignancy Stages of Cervical Cancer Stage 0 – carcinoma insitu 1 – cancer confined to cervix 2 - cancer extends to vagina 3 – pelvis metastasis 4 – affection to bladder & rectum 7. Leopold’s Maneuver Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone - use palm! Warm palm. Prep mom: 1. Empty bladder 15
  16. 16. 2. Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles) Procedure: 1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part to determine presentation 2nd Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound) where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé. Uterine soufflé – maternal H rate 3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers. To determine degree of engagement. Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will not be movable). 4th Maneuver: 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. To determine attitude – relationship of fetus to 1 another. 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 will be flexed and vertex presenting. Attitude – relationship of fetus to a part – or degree of flexion Full flexion – when the chin touches the chest 8.Assessment of Fetal Well-Being- A. Daily Fetal Movement Counting (DFMC) –begin 27 weeks Mom- begin after meal - breakfast a. 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 less 3) Warning signs a.) more then 1 hour to reach 10 movements b.) less then 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 hours 4.) warning signs should be reported to healthcare provider immediately; often require further testing. Examples: nonstress test (NST), biographical profile (BPP) B. Nonstress test – to determine the response of the fetal heart rate to activity Indication – pregnancies at risk for placental insufficiency Postmaturity a.) pregnancy induced hypertension (PIH), diabetes b.) warning signs noted during DFMC c.) 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 1. tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) 2. ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected 3. 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, such as a CST Result: Noncreative 16
  17. 17. Nonstress Not Good Reactive Responsive is Real Good Interpretation of results i. reactive result 1. Baseline FHR between 120 and 160 beats per minute 2. 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 3. 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. 4. result indicates a healthy fetus with an intact nervous system ii. Nonreactive result 1. Stated criteria for a reactive result are not met 2. Could be indicative of a compromised fetus. Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST) 9. Health teachings a. Nutrition – do nutritional assessment – daily food intake High risk moms: 1. Pregnant teenagers – low compliance to heath regimen. 2. Extremes in wt – underweight, over wt – candidate for HPN, DM 3. Low socio – economic status 4. Vegetarian mom – decrease CHON – needs Vit B12 – cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation. (Decrease folic acid – spina bifida/open neural tube defect) How many Kcal CHO x4,CHON x4, fats x 9 Recommended Nutrient Requirement that increases During Pregnancy Nutrients Requirements Food Source Calories 300 calories/day above the Caloric increase should reflect Essential to supply energy for prepregnancy daily requirement to - Foods of high nutrient value such as - increased metabolic rate maintain ideal body weight and meet protein, complex carbohydrates - utilization of nutrients energy requirement to activity level (whole grains, vegetables, fruits) - protein sparing so it can be - Begin increase in second - Variety of foods representing foods used for trimester sources for the nutrients requiring - Growth of fetus - Use weight – gain pattern as an during pregnancy - Development of structures indication of adequacy of - No more than 30% fat required for pregnancy calorie intake. including placenta, amniotic - Failure to meet caloric fluid, and tissue growth. requirements can lead to ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage. Protein 60 mg/day or an increase of 10% Protein increase should reflect Essential for: above daily requirements for age - Lean meat, poultry, fish - Fetal tissue growth group - Eggs, cheese, milk - Maternal tissue growth - Dried beans, lentils, nuts including uterus and breasts Adolescents have a higher protein - Whole grains - Development of essential requirement than mature women since * vegetarians must take note of the amino pregnancy structures adolescents must supply protein for acid content of CHON foods consumed to - Formation of red blood cells their own growth as well as protein t ensure ingestion of sufficient quantities of and plasma proteins meet the pregnancy requirement all amino acids 17
  18. 18. * Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH) Calcium-Phosphorous Calcium increases of Calcium increases should reflect: Essential for - 1200 mg/day representing an - dairy products : milk, yogurt, ice - Growth and development of increase of 50% above cream, cheese, egg yolk fetal skeleton and tooth buds prepregnancy daily - whole grains, tofu - Maintenance of requirement. - green leafy vegetables mineralization of maternal - 1600 mg/day is recommended - canned salmon & sardines w/ bones bones and teeth for the adolescent. 10 mcg/day - Ca fortified foods such as orange - Current research is : of vitamin D is required since it juice Demonstrating an association enhances absorption of both - Vitamin D sources: fortified milk, between adequate calcium intake and calcium and phosphorous margarine, egg yolk, butter, liver, the prevention of pregnancy induce seafood hypertension Iron 30 mg/day representing a doubling of Iron increases should reflect Essential for the pregnant daily requirement - liver, red meat, fish, poultry, - Expansion of blood volume and - Begin supplementation at 30- eggs red blood cells formation mg/day in second trimester, since - enriched, whole grain cereals - Establishment of fetal iron diet alone is unable to meet and breads stores for first few months of pregnancy requirement - dark green leafy vegetables, life - 60 – 120 mg/day along with legumes copper and zinc supplementation - nuts, dried fruits for women who have low - vitamin C sources: citrus fruits & hemoglobin values prior to juices, strawberries, cantaloupe, pregnancy or who have iron broccoli or cabbage, potatoes deficiency anemia. - iron from food sources is more - 70 mg/day of vitamin C which readily absorbed when served enhances iron absorption with foods high in vit C - inadequate iron intake results in maternal effects – anemia depletion of iron stores, decreased energy and appetite, cardiac stress especially labor and birth - fetal effects decreased availability of oxygen thereby affecting fetal growth * iron deficiency anemia is the most common nutritional disorder of pregnancy. Zinc 15mcg/day representing an increase of Zinc increases should reflect Essential for 3 mg/day over prepreganant daily - liver, meats * the formation of enzymes requirements. - shell fish * maybe important in the prevention - eggs, milk, cheese of congenital malformation of the - whole grains, legumes, nuts fetus. Folic Acid, Folacin, Folate 400 mcg/day representing an increase Increases should reflect Essential for of more then 2 times the daily - liver, kidney, lean beef, veal - formation of red blood cells prepregnant requirement. 300mcg/day - dark green leafy vegetables, and prevention of anemia supplement for women with low folate broccoli, legumes. - DNA synthesis and cell levels or dietary deficiency - Whole grains, peanuts formation; may play a role 4 servings of grains/day in the prevention of neutral tube defects (spina bifida), abortion, abruption placenta Additional Requirements Increased requirements of pregnancy can Minerals easily be met with a balanced diet that - iodine 175 mcg/day meets the requirement for calories and 18
  19. 19. - Magnesium 320 mg/day includes food sources high in the other - Selenium 65 mcg/day nutrients needed during pregnancy. Vitamins Vit stored in body. Taking it not needed – E 10 mg/day fat soluble vitamins. Hard to excrete. Thiamine 1.5 mg/day Riborlavin 1.6 mg/day Pyridoxine ( B6) 2.2 mg/day B12 2.2 mg day Niacin 17 mg/day 2.Sexual Activity a.) should be done in moderation b.) should be done in private place c.) mom placed in comfy pos, sidelying or mom on top d.) avoided 6 weeks prior to EDD e.) avoid blowing or air during cunnilingus f.) changes in sexual desire of mom during preg- air embolism Changes in sexual desire: a.) 1st tri – decrease desire – due to bodily changes b.) 2nd trimester – increased desire due to increase estrogen that enhances lubrication c.) 3rd trimester – decreased desire Contraindication in sex: 1. vaginal spotting 1st trimester – threatened abortion 2nd trimester– placenta previa 2. incompetent cervix 3. preterm labor 4. premature rupture of membrane 3. Exercise – to strengthen muscles used during delivery process - principles of exercise 1.) Done in moderation. 2.) Must be individualized Walking – best exercise Squatting – strengthen muscles of perineum. Increase circulation to perineum. Squat – feet flat on floor Tailor Sitting – 1 leg in front of other leg ( Indian seat) Raise buttocks 1st before head to prevent postural hypotension – dizziness when changing position - shoulder circling exercise- strengthen chest muscles - pelvic rocking/pelvic tilt- exercise – relieves low back pain & maintain good posture - * arch back – standing or kneeling. Four extremities on floor Kegel Exercise – strengthen pulococcygeal muscles - as if hold urine, release 10x or muscle contraction Abdominal Exercise – strengthens muscles of abdominal – done as if blowing candle 4. Childbirth Preparation: Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience. a. Psychophysical 1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery process. Based on imitation of nature. Features: 19
  20. 20. 1.) darkened rm 2.) quiet environment 3.) relaxation tech 4.) closed eye & appearance of sleep 2. Grantly Dick Read Method – fear leads to tension while tension leads to pain b. Psychosexual 1. 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 c. Psychoprophylaxis – prevention of pain 1. Lamaze: Dr. Ferdinand Lamaze req. disciple, conditioning & concentration. Husband is coach Features: 1. Conscious relaxation 2. Cleansing breathe – inhale nose, exhale mouth 3. Effleurage – gentle circular massage over abdominal to relieve pain 4. imaging – sensate focus 5. Different Methods of delivery: 1.) birthing chair – bed convertible to chair – semifowlers 2.) birthing bed – dorsal recumbent pos 3.) squatting – relives low back pain during labor pain 4.) leboyers – warm, quiet, dark, comfy room. After delivery, baby gets warm bath. 5.) Birth under H20 – bathtub – labor & delivery – warm water, soft music. IX. Intrapartal Notes – inside ER A. Admitting the laboring Mother: Personal Data: name, age, address, etc Baseline Data: v/s esppecially BP, weight Obstetrical Data: gravida # preg, para- viable preg, – 22 – 24 wks Physical Exams,Pelvic Exams B. Basic knowledge in Intrapartum. b. 1 Theories of the Onset of Labor 1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) – contraction action 2.) oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces oxytocin 3.) prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction 4.) progesterone theory – before labor, decrease progesterone will stimulate contractions & labor 5.) theory of aging placenta – life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor). b.2. The 4 P’s of labor 1. Passenger a. Fetal head – is the largest presenting part – common presenting part – ¼ of its length. Bones – 6 bones S – sphenoid F – frontal - sinciput E – ethmoid O – occuputal - occiput T – temporal P – parietal 2 x Measurement fetal head: 1. transverse diameter – 9.25cm - biparietal – largest transverse - bitemporal 8 cm 2. bimastoid 7cm smallest transverse Sutures – intermembranous spaces that allow molding. 1.) sagittal suture – connects 2 parietal bones ( sagitna) 20
  21. 21. 2.) coronal suture – connect parietal & frontal bone (crown) 3.) lambdoidal suture – connects occipital & parietal bone Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis Fontanels: 1.) Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close 2.) Posterior fontanel or lambda – triangular shape, 1 x 1 cm. Closes – 2 – 3 months. 4.) Anteroposterior diameter - suboccipitobregmatic 9.5 cm, complete flexion, smallest AP occipitofrontal 12cm partial flexion occipitomental – 13.5 cm hyper extension submentobragmatic-face presentation 2. Passageway Mom 1.) < 4’9” tall 2.) < 18 years old 3.) Underwent pelvic dislocation Pelvis 4 main pelvic types 1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy 2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow 3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow 4. Platypelloid – flat AP diameter – narrow, transverse – wider b. Pelvis 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 Pubes – ant portion – symphisis pubis junction between 2 pubis 1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis 1 coccyx – 5 small bones compresses during vaginal delivery Important Measurements 1. 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 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. 3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor a. Involuntary Contractions b. Voluntary bearing down efforts c. Characteristics: wave like d. Timing: frequency, duration, intensity 4. Psyche/Person – psychological stress when the mother is fighting the labor experience a. Cultural Interpretation b. Preparation c. Past Experience d. Support System Pre-eminent Signs of Labor 21
  22. 22. S&Sx: - shooting pain radiating to the legs - urinary freq. 1. Lightening – setting of presenting part into pelvic brim - 2 weeks prior to EDD * Engagement- setting of presenting part into pelvic inlet 2. Braxton Hicks Contractions – painless irregular contractions 3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase epinephrine 4. Ripening of the Cervix – butter soft 5. decreased body wt – 1.5 – 3 lbs 6. Bloody Show – pinkish vaginal discharge – blood & leukorrhea 7. Rupture of Membranes – rupture of water. Check FHT 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 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 form vagina Nursing care: 1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy. 2. Slip cord away from presenting part 3. Count pulsation of cord for FHT 4. Prep mom for CS Positioning – trendelenberg or knee chest position Emotional support Prepare for Cesarean Section Difference Between True Labor and False Labor False Labor True Labor Irregular contractions Contractions are regular No increase in intensity Increased intensity Pain – confined to Pain – begins lower back radiates to abdomen abdomen Pain – intensified by walking Pain – relived by walking Cervical effacement & dilatation * major sx No cervical changes of 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. 22
  23. 23. Nursing Interventions in Each Stage of Labor 2 segments of the uterus 1. upper uterine - fundus 2. lower uterine – isthmus 1. First Stage: onset of true contractions to full dilation and effacement of cervix. Latent Phase: Assessment: Dilations: 0 – 3 cm mom – excited, apprehensive, can communicate Frequency: every 5 – 10 min Intensity mild Nursing Care: 1. Encourage walking - shorten 1st stage of labor 2. Encourage to void q 2 – 3 hrs – full bladder inhibit contractions 3. Breathing – chest breathing Active Phase: Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self Frequency q 3-5 min lasting for 30 – 60 seconds Nursing Care: M – edications – have meds ready A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc. D – dry lips – oral care (ointment) dry linens B – abdominal breathing Transitional Phase: intensity: strong Mom – mood changes with hyperesthesia Assessment: Dilations 8 – 10 cm Frequency q 2-3 min contractions Durations 45 – 90 seconds 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 – ires I – nform of progress R – estless support her breathing technique E – ncourage and praise D – iscomfort Pelvic Exams Effacement Dilation a. 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 b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother -spine of mom and spine of fetus Two types: b.1. Longitudinal Lie ( Parallel) cephalic - Vertex – complete flexion Face 23
  24. 24. Brow Poor Flexion Chin Breech - Complete Breech – thigh breast on abdomen, breast lie on thigh Incomplete Breech – thigh rest on abdominal Frank – legs extend to head Footling – single, double Kneeling b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation. c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis. Variety: Occipito – LOA left occipito ant (most common and favorable position)– side of maternal pelvis LOP – left occipito posterior LOP – most common mal position, most painful ROP – squatting pos on mom ROT ROA Breech- use sacrum LSA – left sacro anterior - put stet above umbilicus LST, LSP, RSA, RST, RSP Shoulder/acromniodorso LADA, LADT, LADP, RADA Chin / Mento LMA, LMT, LMP, RMP, RMA, RMT, RMP Monitoring the Contractions and Fetal heart Tone Spread fingers lightly over fundus – to monitor contractions Parts of contractions: Increment or crescendo – beginning of contractions until it increases Acme or apex – height of contraction Decrement or decrescendo – from height of contractions until it decreases Duration – beginning of contractions to end of same contraction Interval – end of 1 contraction to beginning of next contraction Frequency – beginning of 1 contraction to beginning of next contraction Intensity - strength of contraction Contraction – vasoconstriction Increase BP, decrease FHT Best time to get BP & FHT just after a contraction or midway of contractions Placental reserve – 60 sec o2 for fetus during contractions Duration of contractions shouldn’t >60 sec Notify MD Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia Health teachings 1.) Ok to shower 2.)NPO – GIT stops function during labor if with food- will cause aspiration 3.)Enema administer during labor a.)To cleanse bowel b.)Prevent infection c.)Sims position/side lying 12 – 18 inch – ht enema tubing Check FHT after adm enema Normal FHT= 120-160 24
  25. 25. Signs of fetal distress- 1.) <120 & >160 2.) mecomium stain amnion fluid 3.) fetal thrushing – hyperactive fetus due to lack O2 2. Second Stage: fetal stage, complete dilation and effacement to birth. 7 – 8 multi – bring to delivery room 10cm primi – bring to delivery room Lithotomy pos – put legs same time up Bulging of perineum – sure to come out Breathing – panting ( teach mom) Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2nd stage of labor. Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula) Mediolateral – more bleeding & pain, hard to repair, slow to heal -use local or pudendal anesthesia. Ironing the perineum – to prevent laceration Modified Ritgens maneuver – place towel at perineum 1.)To prevent laceration 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby. Mechanisms of labor 1. Engagement - 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External rotation 7. Expulsion Three parts of Pelvis – 1. Inlet – AP diameter narrow, transverse diameter wider 2. Cavity Two Major Divisions of Pelvis 1. True pelvis – below the pelvic inlet 2. False 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: To prevent puerperal sepsis - < 48 hours only – vaginal pack Bolus of Ptocin can lead to hypotension. 3. Third Stage: birth to expulsion of Placenta -placental stage placenta has 15 – 28 cotyledons Placenta delivered from 3-10 minutes Signs of placental separation 1. Fundus rises – becomes firm & globular “ Calkins sign” 2. Lengthening of the cord 3. Sudden gush of blood Types of placental delivery Shultz “shiny” – begins to separate from center to edges presenting the fetal side shiny Dunkan “dirty” – begin to separate form edges to center presenting natural side – beefy red or dirty Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. 25
  26. 26. Nsg care for placenta: 4. Check completeness of placenta. 5. Check fundus (if relaxed, massage uterus) 6. Check bp 7. Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives 8. Monitor hpn (or give oxytocin IV) 9. Check perineum for lacerations 10. Assist MD for episiorapy 11. Flat on bed 12. Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy. 4. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes. Check placement of fundus at level of umbilicus. If fundus above umbilicus, deviation of fundus 1.) Empty bladder to prevent uterine atony 2.) Check lochia a. Maternal Observations – body system stabilizes b. Placement of the Fundus c. Lochia d. Perineum – R - edness E- dema E - cchymosis D – ischarges A – approximation of blood loss. Count pad & saturation Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc e. Bonding – interaction between mother and newborn – rooming in types 1.) Straight rooming in baby: 24hrs with mom. 2.) Partial rooming in: baby in morning , at night nursery Complications of Labor Dystocia – difficult labor related to: Mechanical factor – due to uterine inertia – sluggishness of contraction 1.) hypertonic or primary uterine inertia - intense excessive contractions resulting to ineffective pushing - MD administer sedative valium,/diazepam – muscle relaxant 2.) 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 primi - maternal effect – exhaustion. Fetal effect – fetal distress, caput succedaneum or cephal hematoma - nsg care: monitor contractions and FHR Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding. Earliest sign: tachycardia & restlessness Late sign: hypotension Outstanding Nursing dx: fluid volume deficit Post of mom – modified trendelenberg IV – fast drip due fluid volume def Signs of Hypovolemic Shock: Hypotension Tachycardia 26
  27. 27. Tachypnea Cold clammy skin Inversion of the uterus – situation uterus is inside out. MD will push uterus back inside or not hysterectomy. Factors leading to inversion of uterus 1.) short cord 2.) hurrying of placental delivery 3.) ineffective fundal pressure Uterine Rupture Causes: 1.) 1.)Previous classical CS 2.)Large baby 3.) Improper use of oxytocin (IV drip) Sx: a.) sudden pain b.) profuse bleeding c.) hypovolemic shock d.) TAHBSO Physiologic retraction ring - Boundary bet upper/lower uterine segment BANDL’S pathologic ring – suprapubic depression a.) sign of impending uterine rupture Amniotic Fluid Embolism or placental embolism – amniotic fluid or fragments of placenta enters natural circulation resulting to embolism Sx: dyspnea, chest pain & frothy sputum prepare: suctioning end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body – eyes, nose, etc. Trial Labor – measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor Multi: 8 – 14, primi 14 – 20 Preterm Labor – labor after 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 rest 2. avoid sex 3. empty bladder 4. drink 3 -4 glasses of water – full bladder inhibits contractions 5. consult MD if symptoms persist Hosp: 1. If cervix is closed 2 – 3 cm, dilation saved by administer Tocolytic agents- halts preterm contractions.YUTOPAR- Yutopar Hcl) 150mg incorporated 500cc Dextrose piggyback. Monitor: FHT > 180 bpm Maternal BP - <90/60 Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IV Tocolytic (Phil) Terbuthaline (Bricanyl or Brethine) – sustained tachycardia Antidote – propranolol or inderal - beta-blocker If cervix is open – MD – steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDS Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia. 27
  28. 28. X. Postpartal Period 5th stage of labor after 24hrs :Normal increase WBC up to 30,000 cumm Puerperium – covers 1st 6 wks post partum Involution – return of repro organ to its non pregnant state. Hyperfibrinogenia - prone to thrombus formation - early ambulation Principles underlying puerperium 1. To return to Normal and Facilitate healing A. Physiologic Changes a.1. Systemic Changes 1. Cardiovascular System - the first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers. 2. Genital tract a. Cervix – cervical opening b. Vaginal and Pelvic Floor c. Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10th day – no longer palpable due behind symphisis pubis 3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a medium for bacterial growth- (puerperal sepsis)- D&C after, birth pain: 1. position prone 2. cold compress – to prevent bleeding 3. mefenamic acid d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia. 1. Ruba – red 1st 3 days present, musty/mousy, moderate amt 2. Serosa – pink to brown 4 – 9th day, limited amt 3. Alba – créme white 10 – 21 days very decreased amt dysuria - urine collection - alternate warm & cold compress - stimulate bladder 3. Urinary tract: Bladder – freq in urination after delivery- urinary retention with overflow 4. Colon: Constipation – due NPO, fear of bearing down 5. Perineal area – painful – episiotomy site – sims pos, cold compress for immediate pain after 24 hrs, hot sitz bath, not compress sex- when perineum has healed II. Provide Emotional Support – Reva Rubia Psychological Responses: a. Taking in phase – dependent phase (1st three days) mom – passive, cant make decisions, activity is to tell child birth experiences. Nursing Care: - proper hygiene b. Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions HT: 1.) Care of newborn 2.) Insert family planting method common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite. – let mom cry – therapeutic. 28
  29. 29. c. Letting go – interdependent phase – 7 days & above. Mom - redefines new roles may extend until child grows. III. Prevent complications 1. Hemorrhage – bleeding of > 500cc CS – 600 – 800 cc normal NSD 500 cc I. Early postpartum hemorrhage– bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding – uterine atony. Complications: hypovolemic shock. Mgt: 1.) massage uterus until contracted 2.) cold compress 3.) modified trendelenberg 4.) IV fast drip/ oxytocin IV drip 1st degree laceration – affects vaginal skin & mucus membrane. 2nd degree – 1st degree + muscles of vagina 3rd degree – 2nd degree + external sphincter of rectum 4th degree – 3rd degree + mucus membrane of rectum Breast feeding – post pit gland will release oxytocin so uterus will contract. Well contracted uterus + bleeding = laceration - assess perineum for laceration - degree of 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 II. Late Postpartum hemorrhage – bleeding after 24 hrs – retained placental fragments Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta, percreta, Acreta – attached placenta to myometrium. Increta – deeper attachment of placenta to myometrium hysterectomy Percreta – invasion of placenta to perimetrium Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum. - too much manipulation - large baby - pudendal anesthesia Mgt: 1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs 2.) shave 3.) incision on site, scraping & suturing Infection- sources of infection 1.)endogenous – from within body 2.) exogenous – from outside 1.) anaerobic streptococci – most common - from members health team 2.) unhealthy sexual practices General signs of inflammation: 1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling) 2. purulent discharges 3. fever 29
  30. 30. Gen mgt: 1.) supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity – for antibiotic prolonged use of antibiotic lead to fungal infection inflammation of perineum – see general signs of inflammation 2 to 3 stitches dislocated with purulent discharge Mgt: Removal of sutures & drainage, saline, between & resulting. Endometriosis – inflammation of endometrial lining Sx: Abdominal tenderness, pos. Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic IV. Motivate the use of Family Planning 1.) determine one’s own beliefs 1st 2.) never advice a permanent method of planning 3.) method of choice is an individuals choice. Natural Method – the only method accepted by the Catholic Church Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen) - clear, watery, stretchable, elastic – long spinnbarkeit Basal Body Temperature 13th day temp goes down before ovulation – no sex - get before arising in bed LAM – 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 pregnant Symptothermal – combination of BBT & cervical. Best method Social Method – 1.) coitus interuptus/ withdrawal - least effective method 2. coitus reservatus – sex without ejaculation – 3. coitus interfemora – “ipit” 4. calendar method OVULATION –count minus 14 days before next mens (14 days before next mens) Origoknause formula – - monitor cycle for 1 year - -get short test & longest cycle from Jan – Dec - shortest – 18 - longest – 11 June 26 Dec 33 - 18 -11 8 - 22 unsafe days 21 day pill- start 5th day of mens 28day pill- start 1st day of mens missed 1 pill – take 2 next day Physiologic Method- Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to become pregnant- 3 months. Consult OB-6mos. Alerts on Oral Contraceptive: 30
  31. 31. -in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she would wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal. - 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. - discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage. Signs of hypertension Immediate Discontinuation A – abdominal pain C – chest pain H - headache E – eye problems S – severe leg cramps If mom HPN – stop pills STAT! Adverse effect: breakthrough bleeding Contraindicated: 1.) chain smoker 2.) extreme obesity 3.) HPN 4.) DM 5.) Thrombophlebitis or problems in clotting factors - if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again. DMPA – depoproveda – has progesterone inhibits LH – inhibits ovulation Depomedroxy progesterone acetate – IM q 3 months - never massage injected site, it will shorten duration Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone. - 5 yrs – disadvantage if keloid skin - as soon as removed – can become pregnant Mechanism and Chemical Barriers Intrauterine 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 IUD HT: 1.) Check for string daily 2.) Monthly checkup 3.) Regular pap smear Alerts; - prevents implantation - most common complications: excessive menstrual flow and expulsion of the device (common problem) - others: P eriod late (pregnancy suspected) Abnormal spotting or bleeding A bdominal pain or pain with intercourse I nfection (abnormal vaginal discharge) N ot feeling well, fever, chills S trings lost, shorter or longer Uterine inflammation, uterine perforation, ectopic pregnancy 31
  32. 32. Condom – latex inserted to erected penis or lubricated vagina Adv; gives highest protection against STD – female condom Alerts: Disadvantage: - it lessen sexual satisfaction - it gives higher protection in the prevention of STDs Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSABLE Ht: 1.) proper hygiene 2.) check for holes before use 3.) must stay in place 6 – 8 hrs after sex 4.) must be refitted especially if without wt change 15 lbs 5.) 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 Cervical Cap – most durable than diaphragm no need to apply spermicide C/I: abnormal pap smear Foams, Jellies, Creams Surgical Method – BTL , Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects Vasectomy – cut vas deferense. HT: >30 ejaculations before safe sex O – zero sperm count, safe XI. High Risk Pregnancy 1. Hemorrhagic Disorders General Management 1.) CBR 2.) Avoid sex 3.) Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc) 4.) Ultrasound to determine integrity of sac 5.) Signs of Hypovolemic shock 6.) Save discharges – for histopathology – to determine if product of conception has been expelled or not First Trimester Bleeding – abortion or eptopic A. Abortions – termination of pregnancy before age of viability (before 20 weeks) Spontaneous Abortion- miscarriage Cause: 1.) chromosomal alterations 2.) blighted ovum 3.) plasma germ defect Classifications: a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed b. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation) Types: 1.) Complete – all products of conception are expelled. No mgt just emotional support! 2.) Incomplete – Placental and membranes retained. Mgt: D&C Incompetent cervix – abortion McDonalds procedure – temporary circlage on cervix S/E; infection. During delivery, circlage is removed. NSD Sheridan – permanent surgery cervix. CS 32