maternal & child nursing care [autosaved]

MATERNAL & CHILD
NURSING

GILBERT T. SALACUP RN,MSN
(Sir G )

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 change


SYSTEM
EXTERNAL GENITALIA– VULVA/ PUDENDA


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
thigh


Parumculae Mystiformes – healing of a hymen


7 OPENING OF EXTERNAL GENITALIA

S – kenes Duct (2)
U – rethra
B – artholins Duct (2)
V – agina
A - nus

Uterus – hollow muscular organ, varies in size, weight and
shape, organ of menstruation


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 g


LAYERS OF THE UTERUS
 Endometrium - Muscle layer for menses
 Myometrium - Power of labor
 Peremetrium - Protects the entire uterus

Three Parts of Uterus
Fundus – upper cylindrical layer
Corpus/ Body – upper triangular layer
Cervix – lower cylindrical layer
Isthmus – lower uterine segment
During pregnancy


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

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

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

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
fimbrae

LBERT T. SALACUP RN,MSN

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-ctalis
Pubo-Va-ginalis

PELVIC TYPES
Caldwell – Moloy Classification
G – ynecoid –female pelvis,most favorable for Vaginal birth
A – ndroid – male pelvis,not favorable for Vaginal birth
A - nthropoid-ape,moderate narrow pubic arch,oval shape
P – latypelloid – flat, wide tranverse diameter,short
ateroposterior diameter


MENSTRUATION
E and P
Organ for mens:
 hypothalamus Stimulate hypothalamus
 anterior pituitary gland
 ovaries Release GnRH
 uterus
Stimulate APG

FSH LH

Maturation of ovum/folicle Ovulation


E MENSTRUATION 14th day
Stimulate hypothalamus E P
Release GnRH
Stimulate APG Ovulation/Rupture of Graafian Follicle/Ovulatory

FSH BBT Spinbarkeit Mittleschmerz

Maturation ovum/follicle Stimulate Ovaries to relese E 15th day
Graafian Follicle Start degenerate
Contains 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

CYCLE
Ovarian Uterine/End
Cycle ometrial
Cycle
Menstrual Menstrual

Follicular Proliferative

Ovulatory Secretory

Luteal Ischemic


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

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


 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


Male Reproductive System


EXTERNAL STRUCTURES
Penis
Ma –le organ for copulation
El- ongated cylindrical structure
B – ody
Co- mposed of
Co –rpora cavernosa 2
Co-rpus spongiosum


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
muscle


Testes
2 solid ovoid organs 4-5 cm long
and 2-3 wide,

Leydig cells

- testosterone production


Hypothalamus

GnRH

APG

LH FSH

TESTOSTERONE ANDROGEN BINDING CHON

SPERMATOGENESIS


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)
↓
Urethra

SEMEN
Is 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


SPERM
64 DAYS BEFORE THEY MATURE


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 tension

Ex-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.


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 – 35


Fertilization
Phonones – song of sperm
Capacitation – ability of sperm to release
proteolytic enzyme and penetrate the
ovum

Stages of Fetal G and D
1.Pre Embryonic Stage
Zygote  fertilized ovum (3 – 4 days travel, 4 days
floating)> from fertilization

Morula  mulberry-liked ball containing 16 – 50 cells

Blastocyst  enlarging cell forming a cavity that later
becomes the embryo covered by thropoblast which later
becomes the placenta and membrane

Thropoblast – covering of blastocyst that become
placenta
Implantation  7 – 10 days after fertilization
3 Processes
1. Apposition 2. Adhesion 3. Invasion
S/Sx of Implantation  Slight pain, Slight Vaginal
Spotting


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


Chorionic Villi – 10 – 11 weeks

Chorionic Villi Sampling (CVS) – removal of tissue
from the fetal postion of the developing placenta
 For genetic screening
 Fetal limb defects, missing digits of toes
 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. Chorion

Umbilical 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


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



Diagnostic Test for Amniotic Fluid  Amniocentesis
Purpose: obtain sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac
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 - Done with empty bladder
decreased MSAFP= down syndrome
increase MSAFP = spina bifida or open neural tube defect

Complication
> Most common side effect : INFECTION
> Late : pre term labor
> Early : spontaneous abortion

Indication for Amniocentesis:
> Early in Pregnancy Advance Maternal Age
> Later in Pregnancy Diabetic Mothers

Greenish – Meconium Stains (Fetal Distress)
Yellowish – jaundice, hyperbilirubinemia
Cloudy – Infection


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/S
Ratio- 2:1 signifies fetal lung maturity not capable for RDS

Shake test – amniotic + saline & shake
Definitive test - Phosphatiglyceroli: PG+ definitive test to
determine fetal lung maturity


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,HBV


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


First trimester: Fifth Month
lanugo covers body
1st month - Brain & heartdevelopment actively swallows amniotic fluid
GIT& resp Tract – remains as single tube Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18wks multi
1. 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 patern
2. 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 open
Second Month Hearing response
All vital organs formed, placenta developed Active production of lung surfactant
Corpus luteum – life span – end of 2nd month wrinkled skin
Sex organ formed vernix caseosa present
Embrayo Length – 23cm; Wt – 600g
Meconium is formed
Heart beats rhythmically Third trimester: Period of most rapid growth.FOCUS: weight of fetus
Embrayo Length – 2.5cm; Wt – 2g
Seventh Month – development of surfactant – lecithin
Third Month Lung alveoli mature
Testes begins to descend
Kidneys functional Embrayo Length – 27cm; Wt – 1100g
Buds of milk teeth appear Eighth Month
Fetal heart tone heard – Doppler – 10 – 12 weeks lanugo begin to disappear
Sex is distinguishable Moro reflex
Embrayo Length – 6-8cm; Wt – 19g sub Q fats deposit
Delivery positioned
Second Trimester:FOCUS–length of fetus Nails extend to fingers
Fourth Month Embrayo Length – 31cm; Wt – 1800-2100g
Babinski reflex Ninth Month
fetal heart tone heard fetoscope, 18 – 20 weeks lanugo & vernix caseosa completely disappear
Sole of the foot with creases
buds of permanent teeth appear
Definite sleep/wake patern
Sex differentiation Complete and can determine by
Amniotic fluid decreases
ultrasound
Embrayo Length – 35cm; Wt – 2200-2900g
Embrayo 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

PREGNANCY
– 266 – 294 days/ 37 – 42 weeks Ave. 40wks
Period of viability - 24wks
Abortus – less than 20wks

Terratogens- 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 & 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
Alcohol – lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome
char by microcephaly
Smoking – low birth rate
Caffeine – low birth rate
Cocaine – low birth rate, abruption placenta


TORCH (TERRATOGENIC) INFECTIONS –
VIRUSES

T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat

O – others. Hepa A,Hepa B, HIV, Syphilis

R – rubella – German measles – congenital heart disease, Cleft palate and lip Don’t get
pregnant for 3 months. Vaccine is terratogenic

C – cytomegalo virus – droplet infection, s/s asymtomatic, microcephaly,
hydrocephalus

H – herpes simplex virus –
1st tri – congenital anomalies and spontaneous miscarriage
2nd and 3rd = Premature birth, intrauterine growth Retardation, CS.


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
Hct 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


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 C


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
HxTx: side lying with pillow under hips or modified knee chest position

Thrombophlebitis – presence of thrombus at inflamed blood vessel
increase fibrinogen
increase clotting factor

Pt sign – (+) Homan's sign – pain on cuff during dorsiflexion
milk leg – skinny white legs due to stretching of skin caused by inflammation


Respiratory system – common problem DOB due to enlarged uterus & increase O2 demand
Position- lateral expansion of lungs or side lying position.

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 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 mechanical
increase salivation – ptyalsim – mgt mouthwash

*Hemorrhoids – pressure of gravid uterus. Mgt; hot sitz bath for comfort
Urinary System
Acetyace test – albumin in urine
Benedicts test – sugar in urine


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


Local change: Vagina:
V – C - hadwick’s sign – blue violet discoloration of vagina
I – He - gar's – change of consistency of isthmus (lower uterine segment)
C – Go - odel's sign – change of consistency of cervix

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)


I – ALAM MO BA KUNG IKAW AY
BUNTIS TIS3X IV- PUNTA NA TAU SA PROBABLE
SIGN4X
DAPAT ALAM MO ANG 3
CHADWIKS SIGN,GOODELLS
PS,PS,PS,PS
SIGN,HEGAR SIGN4X
UMPISAHAN NATIN SA MACKDONALD,VONFERNWALD,L
PRESUMTIVE TIVE4X ADIGNS SIGN4X
KUNG GUSTO MO MALAMAN PUT PISKACHECKS
YOUR HANDS UP,UP,UP. SIGNS,BRAXTONHIX SIGN4X
II – SUSO V- BASTA SIGN,PURO SIGN, LHAT
LAKI,AMMENORHEA,FATIGUE, NG SIGN SIGURADONG MAY
SIGN
QUIKENING N/V
DAGDAG MO ANG SL TEST AT
UTERUS LAKI, ANG HCG TEST
STRAIGRAVIDARUM,LINEA Go back to chorus
NEGRA, MELASMA CHOALASMA
III – CHORUS
VI- PUNTA N TAU4X SA POSITIVE
DAHIL DI AKO SIGN
MAKATULOG,NAKATITIG LANG FHT AUDIBLE, ANG TYAN
SAAKING TYAN, GUMAGALAW AT DRIBLE2, AT
OOH DI MAKA TULOG BAKA PAG IN ULTRASOUND MY
NBUNTIS AKO NG BF NYA FETAL OUTLINE.
KAYA NAGKA INSOMIA 4X BACK TO CHORUS

Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory)
First Trimester: ( I am Pregnant)
Focus: bodily changes of preg, nutrition
No 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 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


Psychological task of the father
First Trimester:
 Excitement predominate his behavior
 Confused and left out

 Couvade syndrome

Second Trimester:
 Anxiety is lessen
 Change in appearance of the partner
Third Trimester:
Rewarding time


Pre-Natal Visit:
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
 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


Weight Monitoring
First Trimester:
Normal Weight gain :1.5 – 3 lbs (1lb/month) :1kg
Second trimester:
normal weight gain:10 – 12 lbs(4 lbs/month) (1 lb/wk) : 5kg

Third 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


Obstetrical Data:
Gravida- # of pregnancy
Primigravida – pregnant for the 1st time
Multigravida – Pregnant 2 – 5th times
GrandMultigravida- 6th above
Nulligravida – Never been pregnant

Para - # of viable pregnancy( 20wks AOG)
Primipara – 1st birth to baby Beyond/more than 20wks AOG
Multipara – 2-5th births to baby Beyond/more than 20wks AOG
GrandMultipara – 6th above births to baby Beyond/more than 20wks AOG
Nullipara- not given birth to baby Beyond/more than 20wks AOG
age of viability - 20 – 24 wks
Term - 38 – 42 wks,
Preterm -20 – 37 weeks
abortion <20 weeks

G – ravida = # of Pregnancy
T- erm = # of Term
P-reterm = # of Preterm
A-bortion = # of Abortions
L – iving = # of Living
Nagele’s Rule
Use to determine expected date of delivery

Jan – Mar  +9 months +7 days

Apr – Dec  -3 months +7 days + 1 year


McDonald’s Rule
Determines age of gestation in weeks

FUNDIC HT X 7/8=AOG in WK

Fundic Ht X 7 = AOG in weeks
8
Ex.
Fr sypmhisis pubis to fundus 24 X 7 =21 wks
8


Bartholomew’s Rule
Determines 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 mos


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 1st ½ of preg
5 x 5 = 25 cm

6 x 5 = 30 cm
7 x 5 = 35 cm 2nd ½ of preg
8 x 5 = 40 cm
9 x 5 = 45 cm
10 x 5 = 50 cm

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.


Danger Signs of Pregnancy
A - bdominal Pain  epigastric pain  auro of impending convulsion
B - oardlike Abdomen  Abruptio placenta
B - lurred Vission  pre eclampsia - Scotoma – spots in the eye
B - leeding  abortion/ ectopic pregnancy – 1st trimester
 H Mole/ Incompetent Cervix – 2nd trimester
 Placental Anomalies – 3rd Trimester
B-P↑
C - hills & Fever,
C - erebral Disturbances
D- ischarge ( Mabaho)
E-dema
F-luid – sudden gush – PROM premature rupture of membrane
G-rabeng Pagsusuka -


Pelvic Examination
IE – empty bladder, precaution
Position : dorsal recumbent, lithotomy

Pap smear – done 1st visit
Cytological 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 malignancy
Most common cancer report organ : cervical cancer
Most common site for pap smear – external OS of cervix (squamocolumnar tissue)
Common site of cervical cancer. maternal – speculum (open)
Stages of cervical cancer
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

LEOPOLD’S MANNEUVER
LM1 - fundic grip - determine the presenting parts

LM2 – abdominal/umbilical grip – Fetus back
 PR of mother : uterine soufflé – MHR
 fundic soufflé – FHR
LM3 – Pawlik’s grip - To determine degree of
engagement.
LM4 - pelvic grip –
Attitude –
Full Flexion – when the chin touches the chest


Assessment of Fetal Well-Being
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 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 hours
4.) warning signs should be reported to healthcare provider immediately; often
require further testing. Examples: nonstress test (NST), biographical
profile (BPP)


Nonstress test
to determine the response of the fetal heart rate to activity

Indication
 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


Interpretation of results
Reactive 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 system

Nonreactive 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)


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 -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% fat
including placenta, amniotic fluid,
associated with fetal damage.
and tissue growth.

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 including Adolescents have a higher protein -Dried beans, lentils, nuts
uterus and breasts requirement than mature women -Whole grains
-Formation of red blood cells and since adolescents must supply protein * vegetarians must take note of the
plasma 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 of
associated with onset of pregnancy requirement sufficient quantities of all amino
induces hypertension (PIH) acids


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 yolk
and 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 vegetables
bones and teeth -canned salmon & sardines w/ bones
-Current research is : -Ca fortified foods such as orange juice
Demonstrating an association between -Vitamin D sources: fortified milk,
adequate calcium intake and the prevention margarine, egg yolk, butter, liver, seafood
of pregnancy induce hypertension
Iron 30 mg/day representing a doubling of the Iron increases should reflect
Essential 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, legumes
blood 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 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 of Increases should reflect
Essential 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, peanuts
bifida), abortion, abruption placenta 4 servings of grains/day


Additional Requirements Increased requirements of
Minerals 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 – fat
Thiamine 1.5 mg/day soluble vitamins. Hard to
Riborlavin 1.6 mg/day excrete.
Pyridoxine ( B6) 2.2 mg/day
B12 2.2 mg day
Niacin 17 mg/day


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 embolism
Changes in sexual desire:
1st tri – decrease desire – due to bodily changes
2nd trimester – increased desire due to increase estrogen that enhances lubrication
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


Exercise
strengthen muscle to be used during the delivery process
Walking – best form of exercise
Squatting – strengthen perineum & ↑circulation to the perineum (raise the
buttocks before head to prevent postural hypotension)
Tailor sitting – same purpose with squatting ( Indian seat)
Kegel exercise – strengthen pubococcygeal muscle
Abdominal exercise – muscle of the abdomen ( done as if blowing a candle)
Shoulder circling exercise – strengthen muscle of the chest
Pelvic rocking exercise or pelvic tilt – relieve low back pain & maintain good
posture (arching back for 3 sec)
Principles of exercise
 must be done in moderation
 must be individualized


Psychoprophylaxis – prevention of pain
1. Lamaze: Dr. Ferdinand Lamaze
req. disciple, conditioning & concentration. Husband is coach
Features:
Conscious relaxation
Cleansing breathe – inhale nose, exhale mouth
Effleurage – gentle circular massage over abdominal to relieve pain
imaging – sensate focus

Psychophysical
1. 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 sleep
2. Grantly Dick Read Method – fear leads to tension while tension leads to pain

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


Different Methods of delivery
birthing chair – bed convertible to chair – semifowlers
birthing bed – dorsal recumbent pos
squatting – relives low back pain during labor pain
leboyers – 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 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


Basic knowledge in Intrapartum.
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).


THE 5 P’S OF LABOR
1.Passenger
Fetal head –is the largest presenting part – common presenting part – ¼ of its length.
Bones – 6 bones
E – ethmoid
S – sphenoid
O – occuputal – occiput
F – frontal – sinciput
T – temporal
P – parietal 2 x


Measurement fetal head
1. transverse diameter
biparietal – largest transverse 9.25cm
Bitemporal - 8 cm
bimastoid - 7cm smallest transverse
2.AP diameter
Suboccipitobregmatic – complete flexion
Occipitofrontal – partial flexion - 12cm
Occipitotemporal – largest AP diameter; hyperextended (13.5cm)
Submentobrgmatic - face presentation; poor flexio


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

Moldings
the overlapping of the sutures of the skull to permit passage
of the head to the pelvis


Fontanels
2.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.


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 pelvis
1.2 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 pubis
2.1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis
3.1 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.

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
Psyche/Person
– psychological stress when the mother is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System


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 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
 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


Difference Between True Labor and False Labor
False Labor True Labor
Irregular contractions Regular Contractions
No increase in intensity Increased intensity
Pain – confined to abdomen Pain – begins lower back radiates to abdomen
Pain – relived by walking Pain – intensified by walking
No 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.


First Stage
Onset of true contractions

to
Full dilation and
effacement of cervix

Stages of Labor
Phase Characteristic Nursing Care
Latent Phase Beginning to 3 cm dilatation. C-hest breathing
Dilations: Contraction: mild to short A-mbulation/walking
0 – 3 cm 20-40/sec S-uppot person
6hr in nullipara 4-5hrs in multi E-ncorage voiding q 2-3 hrs

Active Phase: Stronger contractions O-ral care
Dilations 40-60sec q 3-5 min M-edication be readied
4 -7 cm 3hrs in nulli A-sses v/s-Abdominal
2hrs in multi Breathing

Transitional 9cm full dilatation T-ired-loss sense of control
Phase: Very strong contraction I- nform the progress oflabor
Dilations 60-90 sec R-estless- support her w/t
8 – 10 cm breathing tech.


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


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


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


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
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.


Position – relationship of the fetal presenting
part to specific quadrant of the mother’s pelvis.
ROA/LOA
left occipito anterior most common &
favorable position
ROT/LOT – left occipito transverse

ROP/LOP – left occipito posterior
L/R- side of maternal pelvis
Middle – presenting part
ROP/ROT – most common malposition
ROP/LOP – most painful mgt:
pelvis squatting
Breech – sacroplace the stethoscope above
the umbilicus
Chin – mentum
Shoulder – acromnio dorso

NURSING CONSIDERATION DURING THE FIRST STAGE OF LABOR

Ba - th is necessary
R -est on left side lying position
P -erennial preparation (rule of 7)
M -onitor VS especially BP
E -nema
Purpose
Cleanse the bowel
Prevent infection
12 – 18 inches normal length of tube
Lateral sims position
E -ncourage mother to void
N -PO
FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen


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

SECOND STAGE

OF
LABOR
(FETAL STAGE)
Complete dilatation
and

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 time
BULGING OF PERENIUM  surest sign of delivery initiation
PANT & BLOW Breathing- fetal pushing should be done on an open glottis

Mechanism of Labor (ED FIRE RERE)
E -ngagement
D-escent
F-lexion
I-nternal R-otation
E-xtension
R-estitution
E-xternal R-otation
E-xpulsion

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 labor

2 types
 MEDIAN
 Less bleeding

 Less pain

 Easy repair

 Possible urethroanal fistula  major disadvantage

 MEDIOLATERAL
 More bleeding

 More pain

 Hard to repair and slow healing


PELVIS
Two Major Divisions of Pelvis
True pelvis – below the pelvic inlet
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
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


THIRD STAGE OF LABOR
(PLACENTAL STAGE)

Birth of Infant
to
Placental Expulsion
3 – 10 minutes after child birth

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 blood

BRANT – ANDREW’S MANEUVER
 slowly pulling the cord and wind at the clamp
 rapidly  may cause uterine inversion

Types Placental Delivery
SHULTZ (Shiny)
 From center to the edges
 Presenting fetal side

DUNCAN (Dirty)
 Form edges to center
 Presenting the maternal side



Nursing Considerations during placental delivery
Check - placental completenes
Check -Fundus – Massage if Boggy
Check -BP
M-ethergine, methylergonovine mallate (IM)
O-xytocin (IV) if methergine is not present
C-heck perenium for lacerations
A-ssist in episioraphy
V-aginoplasty/ Vaginal Landscape – Virgin again
E-ncourage Flat on bed
Chills-due dehydration.
Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let
mom sleep to regain energy.

FOURT STAGE OF LABOR

(Recovery Stage)

Immediate post Partum

First 1 – 2 hours after
delivery of placenta

 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


Perineum
E - dema
R - edness
E - cchymosis
D - ischarge
A – pproximation

 Fully saturated – 30 – 40 cc

 Weighing – 1 cc = 1 gram Common Board Question


Nursing Consideration during Recovery
F - lat on bed to prevent dizziness
I - f with Chills  give blanket due to dehydration
N - ourishment (progression of meal)
 Clear liquids – gatorade, ginger juice, gelatins
 Full liquid – milk, ice cream
 Soft diet
 Regular diet
C - heck VS/ Pain
Bonding – interaction between mother and newborn
Strict – 24 hours with mother
Partial – morning with mother, night nursery


Complications of Labor
Dystocia – difficult labor related to:
Mechanical factor – due to uterine inertia – sluggishness of contraction
4. Hypertonic or primary uterine inertia-
 intense excessive contractions resulting to ineffective pushing
 MD administer sedative valium,/diazepam – muscle relaxant
7. 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
Best Nursing dx: fluid volume deficit
Post of mom – modified trendelenberg
IV – fast drip due fluid volume def
Signs of Hypovolemic Shock:
Hypo-tension
Tachy-cardia
Tachy-pnea
Co-ld 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
S -hort cord
H -urrying of placental delivery
I -neffective fundal pressure


Uterine Rupture
Causes:
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:

sudden pain, profuse bleeding , hypovolemic shock - TAHBSO
BANDL’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 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.


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 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:
 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 - <90/60
Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IVTocolytic
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.

POSTPARTAL PERIOD
Puerperium – 5th stage of labor, 1st 6 weeks post partum
Characterize by involution
Involution - return to the normal stage of reproductive organ after pregnancy
Hyperfibrinogenia
- prone to thrombus formation
- early ambulation
Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10th day – no longer
palpable due behind symphisis pubis
Puerperal sepsis - 3 days after post partum: sub involuted uterus – delayed healing uterus with big
clots of blood- a medium for bacterial growth- D&C
After, birth pain:
1. position prone
2. cold compress – to prevent bleeding
3. mefenamic acid
Lochia- bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.
Urinary tract:Bladder – freq in urination after delivery- urinary retention with overflow
Colon:Constipation – due NPO, fear of bearing down
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

Post partum Psychological response according to Reva Rubin
Phase Characteristic Nursing Care
Taking In Reflection/Dependent Phase •Encourage to tell story
2-3 days about childbirth experience
Client is Passive •Encourage rest
Taking 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
Method
Letting Go Independent phase Encourage Prenatal Love
Redefining the New Role and positive Family
relationShip


Prevent

Complications


Hemorrhage – bleeding of > 500cc
 CS – 600 – 800 cc normal

 NSD 500 cc

Early 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 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
 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


Late Postpartum hemorrhage
– bleeding after 24 hrs – retained placental fragments
Mgt: D&C or manual extraction of fragments & massaging of uterus
Plancenta Acreta – attached placenta to myometrium.
Plancenta Increta – deeper attachment of placenta to myometrium hysterectomy
Plancenta 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:
 cold compress every 30 minutes with rest period of 30 minutes for 24 hrs
 shave
 incision on site, scraping & suturing


Uterine Atony
 boggy fundus
 profuse bleeding
Interventions
 massage the uterus
 cold compress
 modified trendelenburg
 fast drip IV
 breastfeeding – to release oxytocin

Infection-
Sources of infection
1.)endogenous – from within body
2.) exogenous – from outside
 anaerobic streptococci – most common - from members health team
 unhealthy sexual practices
General signs of inflammation:
 Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)
 purulent discharges
 fever



Gen mgt:
Supportive Care
– CBR, hydration, TSB, cold compress, paracetamol, VITC
culture & sensitivity – for antibiotic
Inflammation of perineum
see general signs of inflammation
 2 to 3 stitches dislocated with purulent discharge

Mgt:
 Removal of sutures & drainage, saline, between & resulting.


Family Planning


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 Formula
o Couple abstains on days that the woman is fertile
o 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 cycle
shortest cycle = minus 18 longest cycle = minus 11
Example: shortest cycle = 28
longest cycle = 35

Shortest cycle: 28 days – 18 = 10
Longest cycle: 35 days – 11 = 24
Fertile pd: 10th to 24th day of cycle = No sexual intercourse


Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen)
 clear, watery, stretchable, elastic – long spinnbarkeit
 Sexual Intercourse may be resumed after 3 – 4 days
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
 Resume Sexual intercourse after 3 – 4 days
 Recommended observation of BBT is 6 menstrual cycle to establish pattern
of fluctuations

Coitus Interuptus – withdrawal - least effective method
Coitus Reservatus - sex w/o ejaculation
Coitus interfemora - between femor

Artificial Method Contraindications
Oral 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 pain
MO- nilial Vaginal Infection
H-eadache
Mi - ld HPN AND Depression
He – adache
E-ye problem
Na - usea /wt, gain S-evere leg cramp
B – reast tenderness

DMPA – Depoprovera
 Contains progesterone
 Depomedroxy progesterone Acetate

 IM q 3 months – never massage the site  may decrease
effectiveness

NORPLANT
 6 match stick like capsules/ rod
 contain progesterone

 sub Q planted

 good for 5 years


Mechanical Device
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:
 Check for string daily
 Monthly checkup
 Regular pap smear

G notes:
 Most common complications: excessive menstrual flow and expulsion of the device
others:
S - trings lost, shorter or longer
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
Uterine inflammation, uterine perforation, ectopic pregnancy

CONDOM
 Made up of latex
 Put in erected penis or lubricated vagina
 Prevents sperm to enter the uterus
 FEMALE CONDOM – higher protection than that of male
Adv; gives highest protection against STD
Disadvantage:
 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


CERVICAL CAP
 More durable than the diaphram

 Could stay on place for more than 24 hours

 No need to apply spermicides

 Contraindicated to – abnormal papsmear

CHEMICAL SPERMICIDES
 FOAMS – most effective

 Jellies

 Creams

 These may cause toxic shock syndrome


SURGICAL METHOD
Bilateral tubal Ligation
@ isthmus
20% probability of reversal
Vasectomy
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


High Risk Pregnancy
Hemorrhagic 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


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 support
Incomplete - placenta and membranes retained. Mgt : D&C
Missed abortion – Fetus die in uterus, but it is not expelled
Habitual abortion – 3 – 6 abortions
INDUCED
Therapeutic abortion  principle of 2 fold effect

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 bleeding
Mo -nitor for vaginal bleeding •Sy- ncope (fainting)
V -ital signs Mgt:
Surgery depending on side
M-onitor I & O
O - vary: oophrectomy
A - dminister IV fluids
U - terus : hysterectomy


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 choriocarcinoma
Assessment:Early signs-vesicles passed thru
the vagina
Hyperemesis gravidarium increase HCG
Fundal height
Vaginal bleeding( scant or profuse)


Early in pregnancy
High levels of HCG
Preeclampsia at about 12 weeks
Late signs hypertension before 20th week
Vesicles look like a “ snowstorm” on sonogram
Anemia, Abdominal cramping
Serious complications :hyperthyroidism,Pulmonary embolus
Nursing 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


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 CS
Sx: Prank, Bright red, Painless bleeding
Dx: Ultrasound
Avoid: sex, IE, enema – may lead to sudden fetal blood loss Double set up: delivery room
may be converted to OR
Assessment:
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

Abruptio Placenta
premature 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 previa

Nursing 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


Placenta succenturiata
1 or 2 more lobes connected to the placenta by a blood vessel may lead
to retained placental fragments if vessel is cut.
Placenta Circumvalata
fetal side of placenta covered by chorion
Placenta Marginata
– fold side of chorion reaches just to the edge of placenta
Battledore Placenta
– cord inserted marginally rather then centrally
Placenta Bipartita
– placenta divides into 2 lobes
Vilamentous Insertion of cord
- cord divides into small vessels before it enters the placenta
Vasa Previa
– velamentous insertion of cord has implanted in cervical OS


Hypertensive Disorders
I. Pregnancy Induced Hypertension (PIH)-
- HPN after 24 wks of pregnancy, resolved 6 weeks post partum.
Gestational Hypertension - HPN without edema & protenuria H without EP
Pre-eclampsia – HPN with edema & protenuria or albuminuria HE P/A
HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count
II. Transissional Hypertension – HPN between 20 – 24 wks

III. Chronic or Pre-existing Hypertension
–HPN before 20 weeks not resolved 6 weeks post partum.

Three Types of Pre-eclampsia
1.) Mild preeclampsia – Earliest sign of preeclampsia
a.) Increase wt due to edema = IE
b.) BP 140/90 = BP 140/90
c.) Protenuria +1 - +2 = P +1 - +2


2. Severe Preeclampsia
Signs present
 : cerebral and visual disturbances, epigastric pain due to
liver edema and oliguria usually indicates an
 impending convulsion. = IC
 BP 160/110 = BP 160/110
 Protenuria +3 - +4 = P +3 +4
3. Eclampsia
with seizure!
Increase BUN – glomerular damage. Provide safety.


Cause of preeclampsia
 Idiopathic or unknown common in primi due to 1st exposure to chorionic villi
 common in multiple pre (twins) increase exposure to chorionic villi
 common to mom with low socioeconomic status due to decrease intake of CHON
Nursing care:
P – romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause
to urinate.
P- prevent convulsions by nursing measures or seizure precaution
1.) dimly lit room . quiet calm environment
2.) minimal handling – planning procedure
3.) avoid jarring bed
P- prepare the following at bedside
- tongue depressor
- turning to side done AFTER seizure! Observe only! for safely.
E – ensure high protein intake ( 1g/kg/day)
- Na – in moderation
A – anti-hypertensive drug Hydralazine ( Apresoline)
C – convulsion, prevent – Mg So4 – CNS depressant
E – valuate physical parameters for Magnesium sulfate


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