TORCH (Terratogenic) Infections viruses CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend

d through birth canal and adversely affect fetal growth and development 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. Dont get pregnant for 3 months. Vaccine is terratogenic C cytomegalo virus H herpes simplex virus Physiological Adaptation of the Mother to Pregnancy

Iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women. Assessment reveals: o Pallor, constipation o Slowed capillary refill o Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia Nursing Care: Nutritional instruction kangkong, liver due to ferridin content, green leafy vegetablealugbati,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: o Iron from red meats is better absorbed iron form other sources o Iron is better absorbed when taken with foods high in Vit C such as orange juice o Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs. 1. B. Edema lower extremities due venous return is constricted due to large belly, elevate legs above hip level. 1 .C. Varicosities pressure of uterus use support stockings, avoid wearing knee high socks use elastic bandage lower to upper 1. D. Vulbar varicosities painful, pressure on gravid uterus, to relieveposition side lying with pillow under hips or modified knee chest position

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 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 1. A. Pathogenic Anemia

1. E. Thrombophlebitis presence of thrombus at inflamed blood vessel pregnant mom hyperfibrinogenemia increase fibrinogen increase clotting factor thrombus formation candidate outstanding sign (+) Homan's sign milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens Mgt:

pectin thats constipatin. Veg petchay, malungay. exercise mineral oil excretion of fat soluble vitamins 3. C. Flatulence avoid gas forming food cabbage 3. D. 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 3. E. increase salivation ptyalsim mgt mouthwash 3. F. 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 5. A. Lordosis pride of pregnancy 5. B. Waddling Gait wkward walking due to relaxation causes softening of joints & bones Prone to accidental falls wear low heeled shoes 5. C. 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:

Bed rest Never massage Assess + Homan sign once only might dislodge thrombus Give anticoagulant to prevent additional clotting (thrombolytics will dilute) Monitor APTT antidote for Heparin toxicity, protamine sulfate 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. 3. Gastrointestinal 1st trimester change 3. A. 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. 3. B. constipation Progesterone resp for constipation. Increase fluid intake, increase fiber diet (fruits: papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.) Except guava has

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

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

B. Local Changes
Local change: Vagina: V Chadwicks 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: o Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema Mgt: FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so dont give at 1st trimester o treat dad also to prevent reinfection o no alcohol has antibuse effect VAGINAL DOUCHE H2O : 1 tbsp white vinegar

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: 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

b. Moniliasis or candidiasis due to candida albecans,

fungal infection. Color white cheese like patches adheres to walls of vagina. Signs & Symptoms: Managemen: antifungal Nistatin, genshan violet, cotrimaxole, canesten Gonorrhea Thick purulent discharge Vaginal warts condifoma acuminata due to papilloma virus Mgt: cauterization 2. Abdominal Changes

Presumptive o Breast changes o Urinary freq o Fatigue o Amenorrhea o Morning sickness o Enlarged uterus o Cloasma o Linea negra o Increased skin pigmentation o Striae gravidarium o Quickening

Probable o Goodel'schange of consistency of cervix o Chadwicksblue violet discoloration of vagina o Hegar'schange of consistency of isthmus o Elevated BBT due to increased progesterone o Positive HCG or (+)preg test

Positive o Ultrasound evidence o (sonogram) full bladder o Fetal heart tone o Fetal movement o Fetal outline o Fetal parts palpable

o Ballottement bouncing of fetus when lower uterine is tapped sharply o Enlarged abdomen o Braxton Hicks contractions painless irregular contractions

b.) Elisa test test for preg detects beta sub unit of HCG as early as 7 10days C.) Home preg kit do it yourself 4. Baseline Data: V/S esp. BP, monitor wt. ( increase wt 1 s t 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

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 babys Layette best time to do shopping. Most common fear let mom listen to FHT to allay fear Lamaze classes

5. Obstetrical Data: nullipara no pregnancy a. Gravida- # of pregnancy b. Para - # of viable pregnancy age of viability: 20 24 wks Term: 37 42 wks, Preterm: 20 37 weeks Abortion: <20 weeks c. Important Estimates: 1. Nageles Rule use to determine expected date of delivery. Get LMP -3+ 7 +1 2. McDonalds Rule to determine age of gestation IN WEEKS FUNDIC HT X 7/8=AOG in WK Fundic Ht X 7 = AOG in weeks 8 3. Bartholomews 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 of preg , square @ month 2nd of preg, x @ month by 5

Pre-Natal Visit:
1. Frequency of Visit: 1st 7 months 1x a month o 8 9 months 2 x a month o 10 once a week o 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 moms record. Sex ( pseudocyesis or false pregnancy on men & women) Couvade syndrome dad experiences what mom goes through lihi) 3. Diagnosis of Pregnancy a.) urine exam to detect HCG at 40 100th day. 60 70 day peak HCG. 6 weeks after LMP- best to get urine exam.

3mos x 3 = 9cm 4 mos x 4 = 16 cm 10 x 5 = 50 cm 5 x 5 = 25 cm

1st of preg

6 x 5 = 30 cm 7 x 5 = 35 cm 2nd 8 x 5 = 40 cm 9 x 5 = 45 cm

of preg

d. tetanus immunizations prevents tetanus neonatum 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: 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. Leopolds 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 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 souffl (FHR) & uterine souffl. Uterine souffl 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 patients 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.

Intrapartal 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 4 Ps of labor 1. Passenger a. Fetal head is the largest presenting part common presenting part of its length. Bones 6 bones S sphenoid F frontal - sinciput E ethmoid O occuputal - occiput T temporal P parietal 2 x 2. Passageway Mom 1.) < 49 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 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 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 & leucorrhea 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 Difference Between True Labor and False Labor FALSE LABOR TRUE LABOR Irregular Contractions are contractions regular No increase in Increased intensity intensity Pain begins lower Pain confined to back radiates to abdomen abdomen Pain relived by Pain intensified by

walking No cervical changes

walking Cervical effacement & dilatation * major sx of true labor.

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 Monitoring the Contractions and Fetal heart Tone Spread fingers lightly over fundus to monitor 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 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 shouldnt >60 sec Notify MD

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. 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

Mom has headache check BP, if same BP, let mom rest. If BP increase , notify MD preeclampsia 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.

Check bp Administer methergine IM (Methylergonovine Maleate) Ergotrate derivatives Monitor hpn (or give oxytocin IV) Check perineum for lacerations Assist MD for episiorapy Flat on bed Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.

Mechanisms of labor 1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External rotation 7. Expulsion 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.

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 o Empty bladder to prevent uterine atony o Check lochia a. Maternal Observations body system stabilizes b. Placement of the Fundus c. Lochia d. Perineum R - edness E- dema E - cchemosis D ischarges A approximation of blood loss. Count pad & saturation Fully soaked pad : 30 40 cc weigh pad. 1 gram=1cc 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

Nsg care for placenta: Check completeness of placenta. Check fundus (if relaxed, massage uterus)

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- 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 - betablocker 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 5th stage of labor after 24hrs :Normal increase WBC up to 30,000 cu mm Puerperium covers 1st 6 wks post partum Involution return of repro organ to its non pregnant state. Hyperfibrinogenia - prone to thrombus formation - early ambulation