MATERNITY NURSING LECTURE ( Arellano University)

ARLENE D. LATORRE R.N. MAN

Pilliterri Maternal and Child Nursing ( 2 volumes) to be checked OB notebook Nurses dictionary Project in Maternity Nursing Quizzes ( short and long)20% Mastery Exams 30% Major exam 40%

TRENDS IN MATERNAL AND CHILD CARE 1. FAMILIES ARE SMALLER IN SIZE THAN IN PREVIOUS DECADES 2. SINGLE PARENTS ARE INCREASING IN NUMBER 3. AN INCREASING NUMBER OF MOTHERS ARE WORKING OUTSIDE THE HOME 4. FAMILIES ARE MORE MOBILE THAN PREVIOUSLY 5. ABUSE IS MORE COMMON THAN EVER BEFORE 6. FAMILIES ARE MORE HEALTH CONSCIOUS THAN EVER BEFORE

FEMALE REPRODUCTIVE SYSTEM: EXTERNAL STRUCTURES ( VULVA/ PUDENDUM) A. MONS PUBIS OR MONS VENERIS = PAD OF FAT OVER THE SYMPHYSIS PUBIS. HAIRLESS & SMOOTH IN CHILDHOOD, IT IS COVERED BY DARK & CURLY HAIR CALLED ESCUTCHEON AFTER PUBERTY. HAIR PATTERN IS TRIANGULAR WITH BASE UP.

B. LABIA MAJORA
= LENGTHWISE, TWO THICK FOLDS OF FATTY SKIN EXTENDING FROM THE MONS TO THE PERINEUM THAT PROTECTS THE LABIA MINORA, URINARY MEATUS AND VAGINAL MUCOSA.

C. LABIA MINORA

= THINNER, LENGTHWISE FOLDS OF HAIRLESS SKIN, ENCIRCLING THE CLITORIS ANTERIORLY (PREPUCE) AND UNITE POSTERIORLY ( FOURCHETTE) .BELOW THE PREPUCE IS CALLED FRENULUM. HIGHLY SENSITIVE TO MANIPULATION AND TRAUMA, THE REASON WHY IT IS OFTEN TORN DURING DELIVERY.
D. VESTIBULE = TRIANGULAR SPACE LOCATED BETWEEN THE LABIA MINORA CONTAINING VAGINAL INTROITUS, URETHRAL MEATUS BARTHOLINS & SKENES GLANDS

E. GLANS CLITORIS = SMALL ERECTILE STRUCTURE; CONTAINS NERVE ENDINGS, SENSITIVE TO TEMPERATURE AND TOUCH. IT IS THE SEAT OF SEXUAL AROUSAL AND EXCITEMENT IN FEMALES. IT IS THE MOST SENSITIVE PART OF A WOMANS BODY. IT IS ALSO THE STRUCTURE THAT GUIDES THE NURSE TO THE URINARY MEATUS.

F. URETHRAL MEATUS = THE EXTERNAL OPENING OF THE URETHRA. SLIGHTLY BEHIND AND TO THE SIDE ARE THE OPENINGS OF THE SKENES GLANDS (PARAURETHRAL GLANDS); THE SECRETIONS OF WHICH HELP TO LUBRICATE THE EXTERNAL GENITALIA. THE SHORTNESS OF THE FEMALE URETHRA MAKES WOMEN MORE SUSCEPTIBLE TO UTI THAN MEN. G. HYMEN . = A TOUGH BUT ELASTIC SEMICIRCLE OF TISSUE THAT COVERS THE OPENING TO THE VAGINA. THE REMNANT OF HYMEN IS CALLED CARUNCULAE MYRTIFORMIS.

H. VAGINAL ORIFICE / INTROITUS = EXTERNAL OPENING OF THE VAGINA, COVERED BY A THIN MEMBRANE ( HYMEN) IN VIRGINS.LOCATED LATERAL TO THE VAGINAL OPENING ON BOTH SIDES ARE THE BARTHOLINS GLANDS ( VULVOVAGINAL GLANDS). IT LUBRICATES THE EXTERNAL VULVA DURING COITUS AND THE ALKALINE PH OF THEIR SECRETION HELPS TO IMPROVE SPERM SURVIVAL IN THE VAGINA. THE GRAFENBERG OR G-SPOT IS A VERY SENSITIVE AREA LOCATED AT THE INNER ANTERIOR ASPECT OF THE VAGINA.

I. FOURCHETTE
= THIN FOLD OF TISSUE FORMED BY MERGING OF THE LABIA MAJORA AND LABIA MINORA BELOW THE VAGINAL ORIFICE. J. PERINEUM = MUSCULAR SKIN COVERED AREA BETWEEN VAGINAL OPENING AND ANUS.

INTERNAL STRUCTURES: A.VAGINA HOLLOW MEMBRANOUS & MUSCULAR CANAL, 3-4 INCHES LONG,DILATABLE, CONTAINS RUGAE (WHICH PERMITS CONSIDERABLE STRETCHING WITHOUT TEARING).IT IS LOCATED IN FRONT OF THE RECTUM & BEHIND THE BLADDER. = PASSAGEWAY OF MENSTRUATION = PASSAGEWAY OF FETUS

= ORGAN OF COPULATION
= SEMEN DEPOSITORY

** DODERLIENS BACILLUS MAINTAINS THE NORMAL FLORA OF THE VAGINA, WHICH MAKES THE pH OF VAGINA ACIDIC, DETRIMENTAL TO THE GROWTH OF PATHOLOGIC BACTERIA.

Functions:

Organ of copulation Discharges menstrual flow Birth canal

pH 4-5 : acidic

RUGAE TRANSVERSE FOLDS OF SKIN IN THE VAGINAL WALL THAT IS ABSENT IN CHILDHOOD, APPEAR AFTER PUBERTY & DISAPPEARS AT MENOPAUSE. FORNIX-FORNICES= THE CERVIX PROJECTS TO THE VAGINA FORMING FOUR RECESSES OR DEPRESSION AROUND ITS UPPER PORTION CALLED FORNICES: ANTERIOR FORNIX, LATERAL FORNICES, POSTERIOR FORNIX.

B. UTERUS

= HOLLOW, MUSCULAR PEAR SHAPED ORGAN LOCATED IN THE PELVIS, WEIGHING 5060 g IN A NON-PREGNAT WOMAN. HELD IN PLACE BY BROAD LIGAMENTS. ABUNDANT BLOOD SUPPLY COMES FROM UTERINE AND OVARIAN ARTERIES.

- DURING PUBERTY, IT INCREASES IN SIZE & REACHES ITS MAXIMUM SIZE AT 17 YRS OLD
- FUNCTONS:

a. ORGAN OF IMPLANTATION ( NIDATION)

AND MENSTRUATION

b. RECEIVES THE OVA FROM THE FALLOPIAN TUBE

c. FURNISHES PROTECTION FOR A GROWING FETUS

DIVISIONS OF THE UTERUS

1.CERVIX = LOWER PORTION CALLED THE NECK a. EXTERNAL CERVICAL OS = DISTAL OPENING TO THE VAGINA b. CERVICAL CANAL = THE CAVITY c. INTERNAL CERVICAL OS = OPENING TO THE UTERUS 2. FUNDUS = UPPERMOST CONVEX PORTION AND CAN BE PALPATED TO DETERMINE UTERINE GROWTH DURING PREGNANCY , TO ASSESS UTERINE CONTRACTIONS DURING LABOR,& INVOLUTION DURING THE POSTPARTUM PERIOD

= MOST VASCULAR PORTION

= NORMAL IMPLANTATION SITE

3. CORPUS BODY OF THE UTERUS WHICH MAKES UP 2/3 OF THE SAID ORGAN. HOUSES THE FETUS DURING PREGNANCY 4.CORNUA THE UPPER PORTION WHERE THE FALLOPIAN TUBES ARE ATTACHED.

LAYERS:
1.PERIMETRIUM = OUTERMOST LAYER, IT IS ATTACHED TO THE BROAD LIGAMENTS & OFFER ADDED SUPPORT TO THE UTERUS

= MOST VASCULAR PORTION

= NORMAL IMPLANTATION SITE

3. CORPUS BODY OF THE UTERUS WHICH MAKES UP 2/3 OF THE SAID ORGAN. HOUSES THE FETUS DURING PREGNANCY 4.CORNUA THE UPPER PORTION WHERE THE FALLOPIAN TUBES ARE ATTACHED.

LAYERS:
1.PERIMETRIUM = OUTERMOST LAYER, IT IS ATTACHED TO THE BROAD LIGAMENTS & OFFER ADDED SUPPORT TO THE UTERUS

2. MYOMETRIUM
= MIDDLE LAYER , EXPELS FETUS DURING BIRTH PROCESS THEN CONTRACTS AROUND BLOOD VESSELS TO PREVENT HEMORRHAGE (OXYTOCIN SITE) 3. ENDOMETRIUM

= INNERMOST LAYER; THIS LAYER UNDERGO CHANGES IN RESPONSE TO THE HORMONES AT VARIOUS PHASES OF THE MENSTRUAL CYCLE & DURING PREGNANCY; IT CONSISTS OF TWO LAYERS:

GLANDULAR LAYER PEELS OFF DURING MENSTRUATION & THICKENS DURING THE PROLIFERATIVE & SECRETORY PHASE BASAL LAYER LAYER ADJACENT TO THE MYOMETRIUM & GIVES RISE TO THE NEW ENDOMETRIUM AFTER MENSTRUATION & DELIVERY.

UTERINE LIGAMENTS:
1.BROAD LIGAMENT SUPPORTS THE SIDES OF THE UTERUS & ASSISTS IN HOLDING THE UTERUS IN ITS NORMAL ANTEVERSION AND ANTEFLEXION POSITION.

2. CARDINAL LIGAMENT LOWER PORTION OF THE BROAD LIGAMENT. IT IS THE MAIN SUPPORT OF THE UTERUS.DAMAGE TO THIS LIGAMENT WILL RESULT TO UTERINE PROLAPSE.

3. UTEROSACRAL LIGAMENT CONNECTS UTERUS TO THE SACRUM

4. ANTERIOR LIGAMENT PROVIDES SUPPORT TO THE UTERUS IN CONNECTION WITH THE BLADDER. OVERSTRETCHING OF THIS LIGAMENT WILL LEAD TO HERNIATION OF THE BLADDER TO THE VAGINA ( CYSTOCELE).
5. POSTERIOR LIGAMENT FORMS THE CUL-DESAC OF DOUGLAS. DAMAGE TO THIS LIGAMENT WILL LEAD TO HERNIATION OF THE RECTUM TO THE VAGINA. ( RECTOCELE)

C. FALLOPIAN TUBES / OVIDUCTS / UTERINE TUBES

= TWO SLENDER MUSCULAR TUBES WHICH ARISES FROM EACH OF THE UPPER CORNER OF THE UTERINE BODY AND EXTEND OUTWARD. PROVIDES A PLACE FOR FERTILIZATION ( CONCEPTION, FECUNDATION, IMPREGNATION) OF OVA BY THE SPERM.

PARTS:
1.INTERSTITIAL =( 1cm) LIES WITHIN THE UTERINE WALL. IT HAS THE SMALLEST LUMEN. 2. ISTHMUS =( 2cm) PORTION CUT OR SEALED DURING TUBAL LIGATION.( BTL)

3. AMPULLA =( 5cm) LONGEST PORTION, EXACT SITE OF FERTILIZATION ( DISTAL 3RD, OUTER 3RD) 4. INFUNDIBULUM =MOST DISTAL PORTION; RIM OF THE FUNNEL IS COVERED BY FIMBRAE THAT HELPS GUIDE THE OVA INTO THE FALLOPIAN TUBE.

FUNCTION:

TRANSPORT OVUM FROM OVARY TO THE UTERUS SITE OF FERTILIZATION

D. OVARIES = ALMOND SHAPED ORGANS LOCATED ON EITHER SIDE OF THE UTERUS. BEFORE PUBERTY, THE OVARIES ARE SMOOTH, FLAT & OVOID ORGANS. AFTER OVULATIONS, THEY ASSUME A NODULAR & PITTED APPEARANCE. FUNCTIONS: = RESPONSIBLE FOR THE PRODUCTION, MATURATION AND DISCHARGE OF OVA AND SECRETION OF ESTROGEN AND PROGESTERONE = ORGAN OF OVULATION

Function

Oogenesis Ovulation Hormone production estrogen & progesterone

LAYERS OF THE OVARY:

1.TUNICA ALBUGINEA - THE OUTERMOST PROTECTIVE LAYER SURROUNDED BY A SINGLE LAYER OF CUBOIDAL EPITHELIUM.

2. CORTEX
- THE FUNCTIONAL LAYER WHICH IS
THE SITE OF OVUM FORMATION & MATURATION. IT CONTAINS THE PRIMORDIAL FOLLICLES, GRAAFIAN

FOLLICLES, CORPUS LUTEUM & CORPUS ALBICANS. - two months intrauterine = 600,000 oogonia - 5 months intrauterine = 6,800,000 - at birth = 2 million oocytes - prepuberty / childhood = 300,000 to 400,000

- 36 years old = 30,000 to 40,000

- menopause = absent

3. MEDULLA - LAYER WHICH CONTAINS THE

BLOOD VESSELS, LYMPHATICS, NERVES & MUSCLE FIBERS.

THE MAMMARY GLANDS

THE FEMALE BREASTS ARE ACCESSORY ORGANS OF REPRODUCTION MEANT TO PROVIDE THE INFANT WITH THE MOST IDEAL NOURISHMENT AFTER BIRTH. STRUCTURES:

LOBES =EACH BREAST CONSISTS OF 15-20 LOBES FOUND IN EACH BREAST WHICH ARE SUBDIVIDED INTO LOBULES LOBULES COMPOSED OF CLUSTERS OF ACINAR CELLS ( RESPONSIBLE FOR MILK PRODUCTION)

3.ACINAR CELLS MILK SECRETING CELLS THAT IS STIMULATED BY PROLACTIN 4.LACTIFEROUS DUCTS = MILK RESERVOIR WHICH OPEN TO THE NIPPLE.

5.AREOLA = DARK PIGMENTED PART AROUND THE NIPPLE

6. MONTGOMERY TUBERCLE = SECRETES FATTY SUBSTANCE TO LUBRICATE NIPPLES 7. NIPPLE = ELEVATED PART OF THE BREASTS CONTAINING 15-20 OPENINGS FROM THE LACTIFEROUS DUCTS 8. COOPERS LIGAMENT = PROVIDES SUPPORT TO THE MAMMARY GLAND

PHYSIOLOGY OF MILK PRODUCTION

** THE PRODUCTION OF BREAST MILK IS NOT ACHIEVED DURING PREGNACY BECAUSE OF THE PREDOMINANCE OF ESTROGEN & PROGESTERONE. ** IMMEDIATELY AFTER THE DELIVERY OF THE PLACENTA, THERE IS MARKED DECREASE OF BOTH ESTROGEN & PROGESTERONE W/C SERVES AS A STIMULUS FOR THE APG TO PRODUCE PROLACTIN. ** PROLACTIN ACTS ON THE ACINI CELLS TO STIMULATE PRODUCTION OF MILK & ARE THEN STORED IN THE LACTIFEROUS DUCTS.

** AS THE INFANT SUCKS, THE PPG IS STIMULATED TO RELEASE THE HORMONE OXYTOCIN CAUSING THE COLLECTING SINUSES OF THE MAMMARY GLANDS TO CONTRACT, FORCING MILK FORWARD THROUGH THE NIPPLES CALLED LET DOWN REFLEX OR MILK EJECTION REFLEX.

HORMONES THAT INFLUENCE THE MAMMARY GLANDS:

ESTROGEN STIMULATES THE DEVELOPMENT OF THE DUCTILE STRUCTURES OF THE BREST PROGESTERONE STIMULATES THE DEVELOPMENT OF THE ACINAR CELLS HUMAN PLACENTAL LACTOGEN PROMOTES BREAST DEVELOPMENT DURING PREGNANCY OXYTOCIN LET DOWN REFLEX PROLACTIN STIMULATE MILK PRODUCTION

MALE REPRODUCTIVE SYSTEM: ANDROLOGY

B.

Penis: the male organ of copulation; a cylindrical shaft consisting of: a. corpora cavernosa -two lateral columns of erectile tissue b. corpus spongiosum - encases the urethra Parts: 1.The glans penis, a cone-shaped expansion of the corpus spongiosum that is highly sensitive in males. 2. Shaft or body 3. Prepuce or Foreskin retractable skin covering the glans & removed during circumcision. Unretractable or tight foreskin is called PHIMOSIS. -Erection is stimulated by parasympathetic nerve C. Scrotum: a pouch hanging below the penis that contains the testes.

INTERNAL STRUCTURES: A.TESTES = TWO OVOID SHAPED BODY THAT LIE INSIDE THE SCROTUM

= ENCASED BY A PROTECTIVE WHITE FIBROUS CAPSULE AND COMPRISES A NUMBER OF LOBULES

= EACH LOBULE CONTAINS INTERSTITIAL

CELLS ( LEYDIGS CELLS) AND SEMINIFEROUS TUBULES

= SEMINIFEROUS TUBULES PRODUCE SPERMATOZOA = LEYDIGS CELLS PRODUCE THE HORMONE TESTOSTERONE

FUNCTIONS OF THE TESTES:

1. SPERMATOGENESIS = PROCESS BY WHICH THE SPERMATOCYTES ARE DEVELOPED INTO MATURE SPERMATOZOA 2. HORMONE PRODUCTION a. TESTOSTERONE = AN ANDROGEN OR MUSCULINIZING HORMONE RESPONSIBLE FOR ** GROWTH & DEVELOPMENT OF SECONDARY SEX CHARACTERISTICS

b. FSH = FOLLICLE STIMULATING HORMONE

= CAUSES RAPID SPERM PRODUCTION BY THE TUBULE

c. ICSH INTERSTITIAL CELL STIMULATING HORMONE

= STIMULATES LEYDIGS CELLS TO INCREASE TESTOSTERONE PRODUCTION

MALE REPRODUCTIVE SYSTEM:

B. Internal Structures
1. Epididymis: serves as reservoir for sperm storage and maturation. Approximately 20 ft. it takes 12-20 days for the sperm to travel the length of Epididymis. A total of 64 days before they reach maturity. (Treatment= 2 months). Aspermia (absence of sperm) Oligospermia- if < 20 million sperm/ ml 2. Vas deferens: a duct extending from epididymis to the ejaculatory duct and seminal vesicle, providing a passageway for sperm. Varicocele- varicosity of internal spermatic cord Vasectomy (male birth control) 3. Seminal vesicle: are two convoluted pouches that lie along the lower portion of the bladder and empty into the urethra by the way of ejaculatory ducts

MALE REPRODUCTIVE SYSTEM: 4. Ejaculatory duct: the canal formed by the union of the vas deferens and the excretory duct of the seminal vesicle, which enters the urethra at the prostate gland. 5. Prostate Gland: located just below the urinary bladder. Secretes alkaline and most of the seminal fluid. 6. Bulbourethral glands or Cowpers Gland: adds alkaline fluid to the semen. Counterpart of the Bartholins glands in females. 7. Urethra: the passageway for both urine and semen, extending from the bladder to the urethral meatus. (8 inches in long)

SEMINAL FLUID / SEMEN:

= A GRAYISH WHITISH SUBSTANCE CONTAINING SPERMATOZOA AND FRUCTOSE RICH SUBSTANCES. = AT THE TIME OF EJACULATION, APPROXIMATELY 3-5 ML OF SEMEN IS SECRETED WITH ABOUT 100 MILLION SPERMATOZOA PER ML, OR ABOUT 250-500 MILLION SPERMATOZOA AT EACH EJACULATION. IF THE SPERM COUNT DROPS TO LESS THAN 20 MILLION PER ML OF SEMEN, THE RATE IS CONSIDERED INFERTILE.

During ejaculation, semen receives contributions of fluid from Prostate gland (60%) Seminal vesicle (30%) Epididymis ( 5%) Bulbourethral gland (5%)

Testes Contain Leydig cells produces testosterone

ALERT: it takes 64 days for sperm to reach maturity

Testosterone
Stimulates APG secrete FSH & LH

stimulates seminiferous tubules to produce spermatozoa

Testes ---produces sperms Epididymis conducts sperm to Vas deferens

Seminal vesicles ( secretion of fructose & protein)

Ejaculatory duct
Urethra ( 8 inches) ( cowpers gland secretes alkaline fluid)

OUT

Female Glans Clitoris Labia majora Vagina Ovaries Fallopian tubes Skenes glands Bartholins glands Ovum

Male Glans penis Scrotum Penis Testes Vas deferens Prostate glands Cowpers glands Spermatozoa

PUBERTAL DEVELOPMENT: Puberty =is the stage of life IN which the secondary sex
characteristics changes; = stage when the reproductive organs become functional. Girls- age 9 to12 years Theory: must reach a critical weight of approx. 95lbs (43kg) Boys- age 12 to 14 years The role of Androgen- hormones responsible for :

Testosterone -1 androgenic hormone In girls, testosterone influences the development of labia majora, clitoris, and axillary & pubic hair latter termed as (adrenarche)

1.Muscular development 2.Physical growth 3.Increase sebaceous gland secretion (acne)

SEQUENTIAL ORDER OF PUBERTAL CHANGES IN GIRLS: 1. GROWTH SPURT 2. INCREASE IN THE TRANSVERSE DIAMETER OF THE PELVIS 3. BREAST DEVELOPMENT (THELARCHE)

4. GROWTH OF PUBIC HAIR

5. ONSET OF MENSTRUATION (MENARCHE)

6. GROWTH OF AXILLARY HAIR(ADRENARCHE)

7. VAGINAL SECRETIONS

SEQUENTIAL ORDER OF PUBERTAL CHANGES IN BOYS:

1. INCREASE IN WEIGHT

2. GROWTH OF TESTES
3. GROWTH OF FACE, AXILLARY & PUBIC HAIR

4. VOICE CHANGES
5. PENILE GROWTH 6. INCREASE IN HEIGHT 7. SPERMATOGENESIS

CLIMACTERIC PERIOD (AGE 50 YEARS)

1. ATROPHY OF GENITALS GRADUALLY OCCURS 2. PUBIC HAIR THINS 3. PENIS BECOMES FLABBY

MENSTRUAL CYCLE / FEMALE REPRODUCTIVE CYCLE

= EPISODIC UTERINE BLEEDING IN RESPONSE TO HORMONAL CHANGES

= PERIODIC SERIES OF CHANGES THAT RECUR IN THE UTERUS AND ASSOCIATED ORGANS BEGINNING AT PUBERTY AND ENDING AT MENOPAUSE

= TAKEN FROM THE FIRST DAY OF MENSTRUATION TO THE FIRST DAY OF THE NEXT MENSTRUATION

Basis for menstrual cycle is 6-12 month graphing.

Menarche first menstrual period that occurs typically at age 12 but may occur as early as 9 or as late as 17. Thelarche is the development of the breast buds that occur at puberty. Adrenarche is the development of pubic & axillary hair due to androgen stimulation.

MENSTRUATION = PERIODIC, SLOUGHING OFF OF THE ENDOMETRIUM WHICH OCCURS EVERY 28 DAYS BUT COULD BE ANYWHERE FROM 25 TO 35 DAYS & LASTS FOR 3-5 DAYS.

Characteristic of Menstrual Blood:

1. Does not appear to clot 2. Dark red as that of venous blood 3. Offensiveness ( Fleshy stale odor)

BODY STUCTURES INVOLVED IN MENSTRUATION; 1. HYPOTHALAMUS ultimate initiator of menstrual cycle. Secretes GnRH. Releases FSHRF during the first half of the cycle & LHRF during the second half of the cycle. 2. ANTERIOR PITUITARY GLAND releases the gonadotropin hormones (GH) FSH & LH 3. OVARIES- site of ovulation & releases estrogen & progesterone. 4. UTERUS the organ from which menstrual discharge is formed. The changes in the uterine endometrium are due to ovarian hormones

PITUITARY HORMONES ( GONADOTROPIC HORMONES) WHICH REGULATE MENSTRUAL CYCLIC ACTIVITIES:

1. FOLLICLE STIMULATING HORMONE ( FSH) 2. LUTEINIZING HORMONE ( LH ) OVARIAN HORMONES WHICH REGULATE MENSTRUAL CYCLE ACTIVITIES: 1. ESTROGEN hormone of women; produced by the graafian follicle 2. PROGESTERONE hormone of mothers; produced by the corpus luteum

Diseases of the hypothalamus causing a deficiency of this releasing factor can result in delayed puberty. Diseases causing early activation of the GnRH can lead to abnormally early sexual development or precocious puberty

PHASES OF THE MENSTRUAL CYCLE 1. PROLIFERATIVE/ FOLLICULAR/ ESTROGENIC/PREOVULATORY/POST MENSTRUAL 2. SECRETORY/ LUTEAL/ PROGESTATIONAL POST OVULATORY 3. PREMENSTRUAL OR ISCHEMIC PHASE 4. MENSTRUAL PHASE

Consists of the ff phases 1. Menstrual phase 2. Proliferative phase 3. Secretory phase 4. Ischemic phase

Day 1- day 5 First day of bleeding is the first day of cycle Stratum functionale is shed Total blood loss during menses range from 30-80 ml. 60 ml average! More than 80ml blood loss is considered excessive- need for iron supplements Ave daily loss of iron is 0.5 to 1mg

Day 6- day 14 of a 28 day cycle The very low estrogen level during menstruation stimulates hypothalamus to secrete FSHRF, which in turn stimulates the APG to secrete FSH Estrogen is lowest on the 3rd day of the menstrual cycle & highest a day before ovulation

Day 15- day 28 Endometrium becomes thicker and glands secrete nutrients Uterus is prepared for implantation Due to progesterone If no fertilization constriction vessels menstruation

Ischemic
Menstrua l phase

Proliferative phase

Secretory phase

Uterine phase

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Follicular phase Luteal phase Ovarian phase

Ovulatory Phase

If fertilization does not occur, the corpus luteum shrivels as its life span is only 8-10 days from date of ovulation. On the 26th day of a 28 day cycle, if pregnancy has not occurred, the corpus luteum begins to degenerate and becomes corpus albicans. Two days after, menstruation occurs

OVARIAN cycle
Consists of three phases 1. Pre-ovulatory : follicular phase 2. Ovulatory phase 3. Post-ovulatory : Luteal phase

Variable in length: day 6- day 13 Dominant follicle matures and becomes graafian follicle with primary oocyte FSH increases initially then decreases because of estrogen increase

Day 14 Rupture of the graafian follicle releasing the secondary oocyte Due to the LH surge MITTELSCHMERZ- pain during rupture of follicle

Day 15- day 28 MOST CONSTANT 14 days after ovulation Corpus luteum secretes Progesterone If no fertilization happens, corpus luteum will become corpus albicans then degenerate Decreased estrogen and progesterone

SIGNS OF OVULATION
1. MITTLESCHMERZ = A CERTAIN DEGREE OF PAIN FELT AT THE LOWER LEFT OR RIGHT ILIAC 2. CERVICAL MUCUS METHOD OR BILLINGS METHOD = CHANGES IN CERVICAL MUCUS SECRETIONS TO CLEAR, ELASTIC & WATERY ( MOST RELIABLE SIGN).

3. The distensible quality of the cervical mucus wherein it becomes profuse and thin and can be pulled into long strands & suspended like in two glass slides is called SPINNBARKEIT. Spinnbarkeit test does not indicate the exact time of ovulation but signals that a woman is nearing ovulation. This sign is characterized by cervical mucus that is thin, watery and transparent, abundant and highly stretchable. When dried and viewed under the microscope, the mucus reveals a fern pattern. The fern pattern is due to elevated levels of sodium chloride.

Ferning or arborization of cervical mucus At the height of estrogen stimulation just before ovulation Ferning- due to crystallization of sodium chloride on mucus fibers

Involves taking the temperature every morning BEFORE the woman gets out of bed and recording it The temperature drops slightly 24 hours before ovulation, then rises to about half a degree higher than normal and remains thus for up to three days: UNSAFE period! Not a very efficient method unless combined with calendar and mucus methods

6. MOOD CHANGES DUE TO HORMONAL CHANGES

7. BREAST CHANGES AND ENLARGEMENT AND NIPPLES BECOME ERECT

8. INCREASED LIBIDO

FUNCTIONS OF ESTROGEN:
1. ASSISTS WITH THE MATURATION OF THE PRIMARY FOLLICLE

2. CAUSES THICKENING OF THE ENDOMETRIUM, STIMULATES GROWTH OF VAGINA & UTERUS 3. RESPONSIBLE FOR THE DEVELOPMENT OF SECONDARY SEX CHARACTERISTICS ( BREAST DEVELOPMENT) 4. INHIBITS FSH PRODUCTION
5. INCREASES CONTRACTIONS OF THE MYOMETRIUM

6. INCREASES CONTRACTIONS OF THE FALLOPIAN TUBES

7. INCREASES QUANTITY AND PH OF CERVICAL MUCUS CAUSING IT TO BECOME THIN & WATERY & CAN BE STRETCHED TO A DISTANCE OF 10-13CM ( SPINNBARKHEIT TEST OF ELASTICITY)
8. STIMULATES UTERINE CONTRACTIONS

FUNCTIONS OF PROGESTERONE:
1. INCREASES BBT( THERMOGENIC EFFECT) 2. PREPARES THE ENDOMETRIUM FOR IMPLANTATION BY INCREASING GLYCOGEN, ARTERIAL BLOOD, SECRETORY GLANDS, AMINO ACIDS AND WATER.

3. MAINTAINS PREGNACY BY INHIBITING UTERINE CONTRACTIONS

4. INHIBITS THE PRODUCTION OF LH 5. PROMOTES GROWTH OF THE ACINI CELLS OF THE BREASTS

CAUSES SECRETORY CHANGES IN THE ENDOMETRIUM IN PREPARATION FOR IMPLANTATION

FUNCTIONS OF PITUITARY HORMONES 1. FOLLICLE STIMULATING HORMONE (FSH)

= STIMULATES THE DEVELOPMENT OF GRAAFIAN FOLLICLE & THE OVUM

= MAKES THE OVUM MATURE 2. LUTEINIZING HORMONE ( LH) = STIMULATES OVULATION AND DEVELOPMENT OF CORPUS LUTEUM

1. Dysmenorrhea painful menstruation

2. POLYMENORRHEA = TOO FREQUENT MENSTRUATION OCCURING AT INTERVALS OF LESS THAN THREE WEEKS 3. MENORRHAGIA = EXCESSIVE MENSTRUAL BLEEDING 4. METRORRHAGIA = BLEEDING BETWEEN PERIODS; INTERCYCLIC BLEEDING 5. HYPOMENORRHEA = ABNORMALLY SHORT MENSTRUATION 6. HYPERMENORRHEA = ABNORMALLY LONG MENSTRUATION 7. AMENORRHEA absence of menses 8. OLIGOMENORRHEA decreased menstrual flow

SEXUAL RESPONSE CYCLE 1. EXCITEMENT PHASE = OCCURS WITH PHYSICAL, PSYCHOLOGICAL ( SIGHT, SOUND, EMOTION OR THOUGHT) STIMULATION THAT CAUSES PARASYMPATHETIC NERVE STIMULATION = VAGINAL LUBRICATION OCCURS, ARTERIAL DILATION & VENOUS CONSTRICTION IN THE GENITAL AREA, OVERALL MUSCLE TENSION INCREASES. IN MEN, ERECTION INCREASES, CR,RR,BP INCREASES

2. PLATEAU PHASE = NIPPLES BECOME FURTHER ENGORGED. IN MEN, VASOCONGESTION LEADS TO FULL DISTENTION OF THE PENIS, FLUSHING OCCURS SEX FLUSH, BREATHING BECOMES DEEPER, CR,RR & BP INCREASE MARKEDLY 3. ORGASMIC PHASE = SHORTEST STAGE IN THE SEXUAL RESPONSE CYCLE, STRONG MUSCULAR CONTRACTIONSBOTH VOLUNTARY & INVOLUNTARY IN MANY PARTS OF THE BODY, RR,CR DOUBLES AND BP INCREASING AS MUCH AS 1/3 ABOVE NORMAL.

4. RESOLUTION PHASE = GENERALLY TAKES APPROXIMATELY 30 MINUTES FOR BOTH MEN & WOMEN , GENERAL MUSCLE RELAXATION OCCURS, EXTERNAL & INTERNAL ORGANS TO UNAROUSED STATE.

** REFRACTORY PHASE IN MEN

FETAL DEVELOPMENT
OVUM:
1. IT IS THE FEMALE SEX CELL OR FEMALE GAMETE.

2. REGULARLY RELEASED BY THE OVARY BY OVULATION

3. ONLY ONE OVUM REACHES MATURITY EVERY MONTH 4. OVUM HAS 2 LAYERS OF PROTECTIVE COVERING ; A RING OF FLUID CALLED ZONA PELLUCIDA, & A CIRCLE OF CELLS CALLED CORONA RADIATA = these structures increase the bulk of the ovum, facilitating its migration to the uterus.

** OVUM CAN STAY VIABLE & IS CAPABLE OF BEING FERTILIZED FOR 12-24 HOURS AFTER OVULATION BUT CAN LIVE UP TO 3-4 DAYS.

** ONLY ONE SPERMATOZOON IS ABLE TO PENETRATE THE CELL MEMBRANE OF THE OVUM AFTERWHICH THE OVUM BECOMES IMPERVIOUS TO OTHER SPEMATOZOA. 2 KINDS OF SPERM CELL:
1. GYNOSPERM X CARRYING SPERM CELL. It has a large oval head, lesser in number than androsperms & thrive better in acidic environment. 2. ADROSPERM Y CARRYING CELL. It has a small head & thrive better in alkaline environment

SPERM CELL: ** HAS 3 PARTS : HEAD THAT CONTAIN CHROMATIN MATERIALS; NECK OR MID PIECE THAT PROVIDE ENERGY & TAIL THAT IS RESPONSIBLE FOR ITS MOTILITY.

**SPERMATOZOA DEPOSITED IN THE VAGINA . REACHES THE WAITING EGG IN THE FALLOPIAN TUBE IN ABOUT 5 MINUTES
** THE FUNCTIONAL LIFE OF SPERMATOZOA IS 4872 HRS (OR 3 TO 4 DAYS AFTER EJACULATION) BUT CAN STAY ALIVE IN THE VAGINA FOR 5 -7 DAYS.

Deposition of the sperm in the female internal organs which occur during sexual intercourse Although millions of sperms are deposited in the vagina, only a few reach the uterus because many of them are immobilized by the acidic vaginal environment

A.FERTILIZATION ( CONCEPTION, FECUNDATION, IMPREGNATION) = IT IS THE UNION OF A MATURED EGG AND A SPERM & THE PRODUCT IS CALLED A CONCEPTUS OR ZYGOTE. =IT OCCURS AT THE DISTAL 3RD OF THE FALLOPIAN TUBE THE AMPULLA Before fertilization can happen, two things must occur: 1. Ovulation 2. Insemination

** When the sperm cell reaches the uterus, it removes its protective covering, a process called CAPACITATION, the outer covering at the head of the sperm cell disappears & tiny holes appear on it.
** when it meets the ovum in the fallopian tube it secretes the enzymes HYALURONIDASE through the holes in its head which dissolves the outermost covering of the egg cell, the corona radiata (a process called ACROSOME REACTION.) ** when radiata is dissolved, the sperm will again secrete another enzyme called ACROSIN to dissolve a portion of the zona pellucida & will enter the ovum.

** once the sperm cell has entered the ovum & their nucleus has fused together, fertilization is completed. ** the plasma membrane of the ovum will undergo structural changes to prevent POLYSPERMY ( or other sperms cells entering the ovum) ** the hereditary traits & characteristics of a person are found in the cells nucleus in the form of chromosomes. Each strand of chromosome is made up of thousands of genes that are composed of protein substances called deoxyribose nucleic acid (DNA) & ribonucleic acid (RNA)

** REPRODUCTIVE CELLS, DURING GAMETOGENESIS DIVIDE BY MEIOSIS ( HAPLOID NUMBER OF DAUGHTER CELLS) THEREFORE THEY CONTAIN ONLY 23 CHROMOSOMES). = 22 pairs of autosomes = 1 pair of sex chromosomes

** ( BODY CELLS OR SOMATIC CELLS HAVE 46 CHROMOSOMES BEC THEY DIVIDE VIA MITOSIS) ** SPERMS HAVE 23 CHROMOSOMES = 22 AUTOSOMES & 1 X SEX CHROMOSOME OR 1 Y SEX CHROMOSOME. ** THE UNION OF AN X CARRYING SPERM (GYNOSPERM) & A MATURE OVUM RESULTS IN A BABY GIRL (XX) ** THE UNION OF A Y CARRYING SPERM(ANDROSPERM) & A MATURE OVUM RESULTS IN A BABY BOY (XY) ** ONLY FATHERS CAN DETERMINE THE SEX OF THEIR CHILDREN ** SEX OF A CHILD IS DETERMINED AT THE TIME OF FERTILIZATION.

Genes basic units of heredity that detrmine both the physical and cognititve characteristics of people Phenotype refers to his or her outward appearance or the expression of the genes Genotype refers to his or her actual gene composition Genome complete set of genes present

46XX or 46XY

Ex: 46XX5p- = female with 46 chromosomes but with the short arm of chromosome 5 missing( cru de chat syndrome) 47XX21 or 47 XY21 person has an extra chromosome21 ( Trisomy 21 or Downs syndrome)

ZYGOTE: - IS THE FIRST CELL FORMED FROM THE FERTILIZATION OF SPERM & OVUM. - IT CONTAINS 46 CHROMOSOMES: 44 AUTOSOMES & EITHER XX CHROMOSOMES IF THE OFFSPRING IS A FEMALE, OR XY CHROMOSOME, IF THE OFFSPRING IS A MALE. - IT JOURNEYS FROM THE FALLOPIAN TUBE TO THE UTERUS FOR 3-5 DAYS

- 16 HOURS AFTER FERTILIZATION, IT UNDERGOES ITS FIRST CELL DIVISION , BLASTOMERE

- WHEN THERE ARE ALREADY 16 OR MORE BLASTOMERES, THE ZYGOTE IS TERMED MORULA( MORUS MULBERRY) - WHEN IT REACHES THE UTERUS IT IS TRANSFORMED INTO A BLASTOCYST A BALL LIKE STRUCTURE COMPOSED OF AN INNER CELL MASS , CALLED EMBRYONIC DISC OR BLASTOCELE & AN OUTER LAYER OF RAPIDLY DEVELOPING CELLS CALLED TROPHOBLASTS OR TROPHODERM. FLUID FILLS THE SPACES FOUND WITHIN THE CELLS. -

The trophoderm layer gives rise to the placenta, fetal membranes, umbilical cord and amniotic fluid The important functions of the trophoblasts are to: 1) absorb nutrients from the endometrium 2.) secrete a hormone called Human Chorionic Gonadotropin necessary in prolonging the life of the corpus luteum.

TROPHOBLASTS OR THE OUTER CELLS:

AT ABOUT 3 WEEKS, THE TROPHOBLAST CELLS DIFFERENTIATE INTO TWO DISTINCT LAYERS:
1.CYTOTROPHOBLAST OR LANGHANS LAYER: - INNER LAYER THAT PROTECTS THE FETUS AGAINST SYPHILIS UNTIL THE 2ND TRIMESTER. 2. SYNCYTIOTROPHOBLAST OR SYNCYTIAL LAYER: - OUTER LAYER THAT PRODUCES THE HORMONES 1. HUMAN CHORIONIC GONADOTROPIN (HCG), 2.HUMAN PLACENTAL LACTOGEN (HPL). 3.ESTROGEN & 4.PROGESTERONE.

1.HCG: HUMAN CHORIONIC GONADOTROPIN

- FIRST HORMONE TO APPEAR IN PREGNANCY WHICH SERVES AS THE BASIS FOR PREGNANCY TESTING - SECRETED BY TROPHOBLASTS DURING EARLY PREGNANCY - PREVENTS INVOLUTION OF THE CORPUS LUTEUM, STIMULATES IT TO CONTINUE PRODUCING PROGESTERONE AND ESTROGEN FOR 11-12 WEEKS - 8 10 DAYS AFTER FERTILZATION, HCG IS PRESENT IN THE MATERNAL BLOOD URINE

- FEW DAYS AFTER MISSED MENSES (+) IN THE

2. Human
-

placental lactogen

makes sufficient amount of protein, glucose, and minerals - an insulin antagonist (maternal metabolism of glucose) - ensures that the mothers body is prepared for lactation

129

3.Estrogen - stimulates development of uterine and breast tissues in the mother - increases vascularity and vasodilation in the villous capillaries

130

4. Progesterone - after 11 weeks of pregnancy, placenta takes over the production of progesterone from the corpus luteum - it is a smooth muscle relaxant, prevents uterine contraction by decreasing its contractility - also maintains the endometrium

131

- At the time of implantation, the blastocyst already has differentiated at which two separate cavities appear in the inner structure.1. a large one, the Amniotic cavity which is lined with ECTODERM cells 2. a smaller cavity, the yolk sac, lined with ENDODERM cells ( provides fetal RBC until the embryos hematopoietic system matures on the 12th week after which it atrophies)
- Between the amniotic cavity and the yolk sac, a third layer of cells, the MESODERM forms. The embryo will begin to develop at the point where the three cell layers (ECTODERM, MESODERM, ENDODERM) meet called embryonic shield.

- THE BLASTOCELE OR EMBRYONIC DISC GIVES RISE TO THE THREE PRIMARY GERM LAYERS: ECTODERM, MESODERM, ENDODERM.

PRIMARY GERM LAYERS

TISSUE LAYER ECTODERM ( OUTER LAYER) BODY PORTIONS FORMED NERVOUS SYSTEM, SKIN, HAIR NAILS, SENSE ORGANS, MUCUS MEMBRANES OF NOSE & MOUTH

MESODERM ( MIDDLE LAYER)

CONNECTIVE TISSUE, BONES, CARTILAGE, MUSCLES, TENDONS, KIDNEYS, URETERS, REPRODUCTIVE SYSTEM, HEART, CIRCULATORY SYSTEM, BLOOD CELLS

ENDODERM / ENTODERM ( INNER LAYER)

LINING OF THE GI TRACT,

RESPIRATORY TRACT, TONSILS, PARATHYROID,

THYROID, THYMUS GLANDS,

BLADDER, URETHRA

FETAL MEMBRANES: = this enclose the fetus & the amniotic fluid. They also protect the fetus against ascending bacterial infection. Once the integrity of the membranes are destroyed, the woman is prone to develop infection. 1.CHORIONIC MEMBRANE ( OUTER MEMBRANE) = TOGETHER WITH THE DECIDUA BASALIS GIVES RISE TO THE PLACENTA . IT CONTAINS 1520 COTYLEDONS .

2. AMNIOTIC MEMBRANE ( INNER FETAL MEMBRANE)

= IT IS A SMOOTH, THIN, TOUGH & TRANSLUCENT MEMBRANE DIRECTLY ENCLOSING THE FETUS & THE AMNIOTIC FLUID. IT IS CONTINUOUS WITH THE UMBILICAL CORD & COVER THE FETAL SURFACE OF THE PLACENTA & UMBILICAL CORD.
= AMNION & CHORION DOES NOT CONTAIN NERVE ENDINGS

IMPLANTA IMPLANTATION/NIDATION - THE BLASTOCYST REMAINS FREE FLOATING IN THE UTERINE CAVITY FOR 3-5 DAYS & IMPLANTS IN THE ENDOMETRIUM 6-7 ( 8-10 ) DAYS AFTER FERTILIZATION. - AS IT ATTACHES ITSELF TO THE WALL OF THE UTERUS ( APPOSITION), ITS TROPHOBLAST CELLS RELEASE ENZYMES ALLOWING IT TO BURROW DEEP & THEN ATTACHES INTO THE ENDOMETRIUM ( ADHESION) RESULTING IN RUPTURE OF VESSELS & BLEEDING AT THE IMPLANTATION SITE. IMPLANTATION BLEEDING. AFTERWHICH IT SETTLES DOWN INTO ITS SOFT FOLDS ( INVASION)

IMPLANTATION IS AN IMPORTANT STEP IN PREGNANCY BECAUSE AS MANY AS 50% of zygotes never achieve it.

DECIDUA:

- AFTER IMPLANTATION, THE ENDOMETRIUM IS NOW REFERRED TO AS THE DECIDUA.

LAYERS: 1.DECIDUA BASALIS LAYER WHERE IMPLANTATION TAKES PLACE. IT WILL LATER ON FORM THE MATERNAL SIDE OF THE PLACENTA. 2.DECIDUA CAPSULARIS LAYER WHICH ENCLOSES, ENVELOPES THE BLASTOCYST & BECOMES THE BAG OF WATER. 3. . DECIDUA VERA REMAINING LAYER

AMNIOTIC FLUID: - 500 ML TO 1200 ML AT TERM; AVERAGE 1000 ML; replaced approximately every 3 hours - 99% WATER & 1% SOLID PARTICLES CONTAINING ALBUMIN, UREA, URIC ACID, CREATININE, LECITHIN, SPHINGOMYELIN, BILIRUBIN & VERNIX CASEOSA. - SHOULD BE CLEAR, COLORLESS TO STRAW COLORED WITH TINY SPECKS OF VERNIX CASEOSA. - AMNIOTIC FLUID VOLUME INCREASES DURING PREGNANCY & PEAKS APPROXIMATELY 2 WEEKS BEFORE EDC

fetus contributes to the fluid through urine excretion and absorbs from it by swallowing Hydramnios or polydydaramnios (> 2000 ml)Oligohydramnios (< 500) ml indicates disturbance in kidney function

ABNORMAL AMNIOTIC COLORS: 1. GREEN TINGES OR MECONIUM STAINED IN A NON BREECH PRESENTATION SIGNIFIES FETAL DISTRESS 2. GOLD OR YELLOW SIGNIFIES HEMOLYTIC DISEASE SUCH AS Rh OR ABO INCOMPATIBILITY 3. GRAY INDICATES INFECTION 4. PINK SIGNIFIES BLEEDING

FUNCTIONS OF AMNIOTIC FLUID:

1. PROTECTS THE FETUS FROM TRAUMA, BLOWS & PRESSURE

2. ALLOWS FREEDOM OF MOVEMENT WHICH PERMITS SYMMETRICAL GROWTH & DEVELOPMENT 3.MAINTAINS A CONSTANT TEMPERATURE. 4. SOURCE OF ORAL FLUID INTRAUTERINE. 5. AIDS IN DIAGNOSIS OF MATERNAL & FETAL COMPLICATIONS. 6. AIDS IN FETAL DESCENT DURING LABOR BY PROVIDING LUBRICATION IN THE BIRTH CANAL.

UMBILICAL CORD / FUNIS

-STRUCTURE THAT CONNECTS THE FETUS TO THE PLACENTA

- MAIN FUNCTION IS TO CARRY O2 & NUTRIENTS FROM THE PLACENTA TO THE FETUS & RETURN THE UNOXYGENATED BLOOD & FETAL WASTE PRODUCTS TO THE PLACENTA.

- 50 -55 CMS LONG. APPEARS DULL WHITE,MOIST & COVERED BY AMNION.

- COMPOSED OF 2 ARTERIES & 1 VEIN ( AVA) - IF ONLY TWO BLOOD VESSELS, SUSPECT RENAL AND CARDIAC ANOMALIES.

- 2 arteries carry deoxygenated blood from the fetus to the placenta - 1 vein carries oxygenated blood to the fetus, along with nutrients, hormones etc

** UMBILICAL CORD ORIGINATES FROM THE YOLK SAC & UMBILICAL VESICLES.
** WHARTONS JELLY GELATINOUS SUBSTANCE THAT COVERS THE UMBILICAL CORD TO PREVENT TRAUMA TO THE CORD.

CORD INSERTION: *1. CENTRAL INSERTION NORMALLY, THE CORD IS INSERTED AT THE CENTER OF THE FETAL SURFACE OF THE PLACENTA.

*2. LATERAL INSERTION WHEN THE CORD IS INSERTED AWAY FROM THE CENTER OF THE PLACENTA BUT NOT AT ITS EDGES.

The cord, instead of entering the placenta directly, separates into small vessels that reach the placenta by spreading across a fold of amnion May be found in multiple gestation May be associated with fetal anomalies

MLNG CELESTE, RN, MD

155

The cord is inserted marginally rather than centrally The cord is inserted at the edge of the placenta

Knots of the Cord fetal movements may cause knots in the cord which could lead to perinatal loss. Its incidence is high in monoamniotic twinning. Normal false knots results from kinking to accommodate cord length. Loops of the Cord- the cord may coil around the fetal body and neck. When cord coil is in the neck, it is called nuchal cord.

Umbilical knot

PLACENTA
THE PLACENTA IS FORMED FROM THE CHORIONIC VILLI AND DECIDUA BASALIS. ** ITS GROWTH PARALLELS THAT OF THE FETUS, GROWING FROM A FEW IDENTIFIABLE CELLS AT THE BEGINNING OF PREGNANCY TO AN ORGAN 15 TO 20 CM IN DIAMETER. IT COVERS ABOUT HALF OF THE SURFACE OF THE INTERNAL UTERUS * IT REACHES MATURITY AT 8 WEEKS AND BECOMES FUNCTIONAL AT 12 WEEKS GESTATION ( 3 MONTHS) AND CONTINUE TO FUNCTION EFFECTIVELY UNTIL THE 40 TO 41ST WEEK.. IT BEGINS TO DEGENERATE AFTER THE 42ND WEEK MAKING IT DANGEROUS FOR THE FETUS TO REMAIN IN UTERO BEYOND 42 WEEKS GESTATION. * DEVELOPMENT IS STIMULATED BY PROGESTERONE SECRETED BY THE CORPUS LUTEUM

Placenta - membranous vascular organ connecting the fetus to the mother, supplies the fetus with oxygen and food and transports waste product out of fetal system - development is stimulated by progesterone secreted by corpus luteum ( 3rd wk after fertilization) - fully functional by the 12th week

161

2 sides of placenta:
1.maternal side which is irregular and is divided into subdivisions called cotyledons 2. fetal side covered by amnion, so it is smooth and shiny

162

FUNCTIONS OF THE PLACENTA

1. RESPIRATORY SYSTEM = EXCHANGE OF GASES TAKES PLACE IN THE PLACENTA, NOT IN THE FETAL LUNG 2. RENAL SYSTEM = WASTE PRODUCTS ARE BEING EXCRETED THROUGH THE PLACENTA NOTE: IT IS THE MOTHERS LIVER WHICH DETOXIFIES THE FETAL WASTE PRODUCTS 3. GASTROINTESTINAL SYSTEM = NUTRIENTS PASS TO THE FETUS VIA THE PLACENTA BY DIFFUSION THROUGH THE PLACENTAL TISSUES.

4. CIRCULATORY SYSTEM = FETO PLACENTAL CIRCULATION IS ESTABLISHED BY SELECTIVE OSMOSIS 5. PROTECTIVE BARRIER = INHIBITS PASSAGE OF CERTAIN BACTERIA & LARGE MOLECULES ** PROVIDES MATERNAL IMMUNOGLOBULIN G ( IG G) THAT GIVES FETUS PASSIVE IMMUNITY TO CERTAIN DISEASES FOR THE FIRST FEW MONTHS AFTER BIRTH. 6. ENDOCRINE SYSTEM = PRODUCES HORMONES HCG, HPL ( HUMAN PLACENTAL LACTOGEN CHORIONIC SOMATOMAMMOTROPIN, ESTROGEN , PROGESTERONE, RELAXIN

Placenta Weighs approximately 500 g and is 15 20 cm in diameter, 1.5 3 cm thick Weight is 1/6 of the fetus Maternal and fetal sides

Umbilical cord length:55 cm at term 1 vein (carries oxygenated blood to the fetus) 2 arteries (carry deoxygenated blood from fetus to placenta) Whartons jelly, gelatinous substance Cord extends from the fetal surface of the placenta to the fetal umbilicus

Placenta has 1 or more accessory lobes connected to the main placenta by blood vessels

Ordinarily, chorion membrane begins at the edge of the placenta; no chorion covers the fetal side of the placenta This kind- the fetal side of the placenta is covered with chorion

Placenta Acreta invasion of the placenta deep into the endometrium Placeta increta- invasion of the placenta into the myometrium Placenta percreta penetration of the placenta through the myometrium to the serosa Vasa previa placental vessels crossing the cervical os

The Growing Fetus

STAGES OF FETAL GROWTH AND DEVELOPMENT

A.PRE-EMBRYONIC or GERMINAL STAGE = FIRST 2 WEEKS BEGINNING WITH FERTILIZATION ( ZYGOTE) B. EMBRYONIC = WEEKS 2-8, CONSIDERED THE MOST CRITICAL IN FETAL STAGE BECAUSE OF ORGANOGENESIS. ( EMBRYO)
C. FETAL = WEEKS 8 TO BIRTH ( FETUS)

NORMAL FETAL DEVELOPMENT

( measurement done at end of the lunar month) 4 WEEKS
FORM OF EMBRYONIC DISC, NOT CLEARLY DEFINED FEATURES, SPINAL CORD IS FORMED; RUDIMEN TARY HEART APPEARS AS A PROMINENT BULGE ON THE ANTERIOR SURFACE, ARMS & LEGS BUD LIKE STRUCTURES, RUDIMENTARY EYES, EARS, & NOSE
L = 0.75 to 1 cm W= 400 mg

ARE DISCERNABLE

8 WEEKS

ORGANOGENESIS IS COMPLETE, HEART

BEATS RHYTHMICALLY, , FACIAL FEATURES ARE DISCERNABLE,EXTREMITIES HAVE DEVELOPED,, EXTERNAL GENITALIA PRESENT BUT SEX IS NOT DISTINGUISHABLE PRIMITIVE TAIL IS REGRESSING, ABDOMEN APPEARS LARGE AS FETAL INTESTINES

GROWS RAPIDLY,EYES MOVE FROM FACE TO FRONT SONOGRAM SHOWS

GESTATIONAL SAC ( DIAGNOSTIC OF PREGNANCY)

L= 2.5 cm ( 1 inch) W=20g

L=7 TO 8 CM w- 45G

12 WEEKS

NAIL BEDS FORMING ON FINGERS & TOES, BONE OSSIFICATION BEGINS, TOOTH BUDS PRESENT, SEX DISTINGUISHABLE BY OUTWARD APPEARANCE, KIDNEYS

SECRETE, HEARTBEAT AUDIBLE BY A

DOPPLER

16 WEEKS

FETAL HEART SOUNDS AUDIBLE VIA FETOSCOPE, LANUGO IS WELL FORMED, LIVER & PANCREAS FUNCTIONING, FETUS SWALLOWS AMNIOTIC FLUID SHOWING AN

INTACT BUT UNCOORDINATED

L-10 TO 17CM W-55 TO 120 G

SWALLOWING REFLEX, SEX CAN BE DETERMINED BY ULTRASOUND;QUICKENING FELT BY A MULTIGRAVIDA

20 WEEKS

QUICKENING FELT BY A PRIMAGRAVIDA, ANTIBODY PRODUCTION IS POSSIBLE, HAIR FORMS INCLUDING EYEBROWS & HAIR ON HEAD, MECONIUM PRESENT IN UPPER INTESTINE, BROWN FAT ( AIDS IN TEMPERATURE REGULATION AT BIRTH) BEGINS TO BE FORMED BEHIND THE KIDNEYS, STERNUM, & POSTERIOR NECK,
FETAL HEART AUDIBLE VIA STETHOSCOPE, VERNIX CASEOSA BEGINS TO FORM, DEFINITE SLEEPING PATTERNS ARE DISTINGUISHABLE ( WILL GUIDE SLEEP/WAKE PATTERNS THROUGHOUT LIFE
L= 25 CMS W= 223g

24 WEEKS

PASSIVE ANTIBODY TRANSFER FROM MOTHER TO FETUS BEGINS .INFANTS BORN BEFORE ANTIBODY . TRANSFER HAS TAKEN PLACE HAVE NO NATURAL IMMUNITY & NEED MORE THAN THE USUAL PROTECTION AGAINST INFECTIOUS DISEASE IN THE NEWBORN UNTIL THE INFANTS OWN STORE OF IGS CAN BUILD UP; MECONIUM IS PRESENT IN THE RECTUM; ACTIVE PRODUCTION OF LUNG SURFACTANT BEGINS; EYEBROWS & EYELASHES WELL DEFINED; EYELIDS NOW OPEN; PUPILS REACTIVE TO LIGHT; HEARS IN RESPONSE TO SUDDEN SOUND.
L = 28 TO 36 CMS W= 550g

28 WEEKS

LUNG ALVEOLI BEGINS TO MATURE; SURFACTANT PRESENT IN AMNIOTIC FLUID; TESTES BEGIN TO DESCEND;BLOOD VESSELS OF THE RETINA ARE THIN & EXTREMELY SUSCEPTIBLE TO DAMAGE ( an imp. consideration when caring for preterm infants who need oxygen)
SUBCUTANEOUS FAT BEGINS TO BE DEPOSITED ( THE FORMER STRINGY OLD MAN APPEARANCE IS LOST); FETUS IS AWARE OF SOUNDS OUTSIDE THE MOTHERS BODY; ACTIVE MORO REFLEX PRESENT, BIRTH POSITION( VERTEX OR BREECH) MAY BE ASSUMED; IRON STORES THAT PROVIDE IRON FOR THE TIME THAT THE NEONATE WILL INGEST ONLY MILK AFTER BIRTH ARE BEGINNING TO BE DEVELOPED; FINGERNAILS GROW TO REACH END OF FINGERTIPS.

32 weeks

36 WEEKS

ADDITIONAL AMOUNTS OF SUBCATANEOUS FATS ARE DEPOSITED; SOLE OF THE FOOT HAS ONLY ONE OR TWO CRISSCROSS CREASES; LANUGO BEGINS TO DIMINISH; MOST BABIES TURN INTO A VERTEX OR HEAD-DOWN PRESENTATION DURING THIS MONTH

40 WEEKS
L-48 to 52 cm W3,000g -7 to 7.5 lbs

FETUS KICKS ACTIVELY CAUSING DISCOMFORT TO THE MOTHER; VERNIX CASEOSA IS FULLY FORMED;

** IN PRIMIPARAS, THE FETUS OFTEN SINKS INTO THE BIRTH CANAL DURING THE LAST TWO WEEKS ( UP TO 4 WEEKS), GIVING THE MOTHER A FEELING THAT HER LOAD IS BEING LIGHTENED. THIS IS TERMED LIGHTENING. IT IS A FETAL ANNOUNCEMENT THAT THE THIRD TRIMESTER OF PREGNANCY HAS ENDED AND BIRTH IS AT HAND.**

** THE DURATION OF A NORMAL PREGNANCY IS 266 280 DAYS OR 38-42 WEEKS ( AVERAGE IS 40 WEEKS) ; OR 9 CALENDAR MONTHS OR 10 LUNAR MONTHS. ** BOTH OVULATION & GESTATIONAL AGE ARE ALSO SOMETIMES MEASURED IN LUNAR MONTHS ( 4 WEEK PERIODS) OR IN TRIMESTERS ( 3 MONTH PERIOD) RATHER THAN IN WEEKS. IN LUNAR MONTHS, A PREGNANCY IS 10 MONTHS ( 40 WEEKS OR 280 DAYS) LONG; A FETUS GROWS IN UTERO 9.5 LUNAR MONTHS OR THREE FULL TRIMESTERS ( 38 WEEKS OR 266 DAYS)

PATERNAL REACTIONS TO PREGNANCY: A. FIRST TRIMESTER = AMBIVALENCE & ANXIETY ABOUT ROLE CHANGE; CONCERN FOR IDENTIFICATION WITH MOTHERS DISCOMFORTS ( COUVADE SYNDROME)

B. SECOND TRIMESTER = INCREASED CONFIDENCE & INTEREST IN MOTHERS CARE; DIFFICULTY RELATING TO FETUS; JEALOUSY

SIGNS & SYMPTOMS OF PREGNANCY:

PRESUMPTIVE SIGNS: ( SUBJECTIVE SIGNS SUGGESTIVE OF PREGNANCY)

1. AMENORRHEA of more than 10 days

2. MORNING SICKNESS ( NAUSEA & VOMITING) 4. URINARY FREQUENCY 5. STRIAE GRAVIDARUM 6. CHLOASMA, MELASMA OR MASK OF PREGNANCY 8. QUICKENING 7. LINEA NIGRA 9. LEUKORRHEA

Pink or reddish abdominal streaks (striae gravidarum) which is caused by stretching of the skin Chloasma or mask of pregnancy -Increased pigmentation can occur on the face as blotchy brown areas on the forehead an cheeks linea nigra on the abdomen as dark line from the symphysis pubis Minute vascular spiders may occur The umbilicus is pushed outward, and by about the seventh month its depression disappears and becomes a darkened area on the abdominal wall Sweat and sebaceous glands are more active

LINEA NIGRA

STRIAE GRAVIDARUM

STRIAE ALBICANTES

PROBABLE SIGNS: ( OBJECTIVE SIGNS)

1.CHADWICKS SIGN PURPLISH DISCOLORATION OF THE VAGINA DUE TO HIGH VASCULARITY IN THE AREA. 2. GOODELS SIGN SOFTENING OF THE CERVIX
3. HEGARS SIGN SOFTENING OF THE LOWER UTERINE SEGMENT. 4. BALLOTEMENT BOUNCING OF THE BABY WHEN TAPPED
BY AN EXAMINING FINGER. 5. BRAXTON HICKS PAINLESS UTERINE CONTRACTIONS 6. (+) POSITIVE PREGNANCY TEST 7. Uterine enlargement

POSITIVE SIGNS OF PREGNANCY:

( DEFINITELY PREGNANT) 1. PRESENCE OF FETAL HEART TONE- audible bet. 17-20 wks gestation with the use of ordinary stet audible by doppler at 8 to 10 weeks 2. FETAL OUTLINE BY XRAY / ULTRASOUND may be detected as early as the 6th wk AOG although usually done at 16-18 wks 3. FETAL MOVEMENT FELT BY EXAMINER after 16 wks but usually about 5th month

SYSTEMIC CHANGES:
CIRCULATORY / CARDIOVASCULAR: ** BEGINNING THE END OF THE FIRST TRIMESTER, THERE IS A GRADUAL INCREASE OF ABOUT 30%-50% IN TOTAL CARDIAC VOLUME. THIS CAUSES A DROP IN HgB & HcT VALUES SINCE THE INCREASE IS ONLY IN PLASMA. PHYSIOLOGIC ANEMIA OF PREGNANCY Mx : iron supplement

CONSENQUENCES OF INCREASED CARDIAC VOLUME:

** EASY FATIGABILITY & SOB DUE TO INCREASED WORKLOAD OF THE HEART MX: REST ** SLIGHT HYPERTHOPHY OF THE HEART CAUSING IT TO BE DISPLACED TO THE LEFT ** SYSTOLIC MURMURS DUE TO LOWERED BLOOD VISCOSITY ** NOSEBLEEDS MAY OCCUR DUE TO MARKED CONGESTION OF THE NASOPHARYNX

** PALPITATIONS DUE TO INCREASED PRESSURE ON THE DIAGPHRAGM

** EDEMA OF LOWER EXTERMITIES OCCURS DUE TO POOR CIRCULATION RESULTING FROM PRESSURE OF THE GRAVID UTERUS ON THE BLOOD VESSELS MX; > RAISE LEGS ABOVE HIP LEVEL > AVOID PROLONGED STANDING & SITTING

NOTE: EDEMA OF THE LE IS NOT A SIGN OF TOXEMIA.

** VARICOSITIES COULD OCCUR DUE TO PRESSURE OF THE GRAVID UTERUS ON THE BLOOD VESSELS OF THE LE MX: > DO NOT CROSS LEGS WHEN SITTING > WEAR SUPPORT HOSE TO PROMOTE VENOUS FLOW THUS PREVENTING STASIS IN THE LOWER EXTREMITIES > AVOID USE OF KNEE HIGH SOCKS

** VARICOSITIES OF THE VULVA & RECTUM

MX: > SIDE LYING POSITION WITH HIPS ELEVATED ON PILLOWS > MODIFIED KNEE CHEST POSITION ** THERE IS INCREASED CIRCULATING FIBRINOGEN ( CLOTTING FACTOR) THAT IS WHY PREGNANT WOMEN ARE NORMALLY SAFEGUARDED AGAINST UNDUE BLEEDING. HOWEVER THIS ALSO PREDISPOSES THEM TO CLOT FORMATION ( THROMBI)

IMPLICATION: PREGNANT WOMEN SHOULD NOT BE MASSAGED SINCE BLOOD CLOTS CAN BE RELEASED & CAUSE THROMBOEMBOLISM.

** DURING DELIVERY, THE ALLOWABLE BLOOD LOSS IS 250-450 ML (MAXIMUM 500 ML) FOR A SINGLE FETUS, 1000 ML FOR VAGINAL DELIVERY OF TWINS OR CESARIAN SECTION.

** SUPINE HYPOTENSION SYNDROME OR VENA CAVA SYNDROME = THE WEIGHT OF THE GRAVID UTERUS PRESSES ON THE VENA CAVA OBSTRUCTING BLOOD FLOW. THE WOMAN EXPERIENCES LIGHTHEADEDNESS, FAINTNESS & HEART PALPITATIONS.
MX: LEFT SIDE LYING OR LEFT LATERAL SO AS NOT TO COMPRESS THE VENA CAVA. NO SUPINE POSITION AFTER 20 WEEKS AOG

RESPIRATORY SYSTEM: ** SLIGHT DYSPNEA MAY OCCUR UNTIL LIGHTENING CAUSED BY INCREASED O2 CONSUMPTION & PRODUCTION OF CO2 GASTROINTESTINAL SYSTEM: ** MORNING SICKNESS MX: EAT DRY CRACKERS 30 MINUTES BEFORE ARISING IN THE MORNING. AVOID SPICY, FATTY FOODS

HYPEREMESIS GRAVIDARUM ( PERNICIOUS VOMITING) = EXCESSIVE NAUSEA & VOMITING WHICH PERSISTS BEYOND 3 MONTHS THAT COULD RESULT TO DEHYDRATION, STARVATION, MALNUTRITION AND F & E IMBALANCE MX: 3000 ML f Ringers Lactate with added Vit B IN 24 HOURS IS THE PRIORITY OF TREATMENT > REST > ANTI- EMETICS (EX. PLASIL, REGLAN ) - Cause is unknown but women with the disorder may have increased thyroid function d/t the thyroid stimulating properties of HCG

CONSTIPATION = DUE TO DISPLACEMENT OF THE STOMACH & INTESTINES AND DUE TO INCREASED PROGESTERONE DURING PREGNANCY ( DECREASED PERISTALSIS

MX: > INCREASE FLUID INTAKE > HI - FIBER DIET ESTABLISH REGULAR ELIMINATION PATTERN EXERCISE

> MINERAL OIL SHOULD NOT BE USED BECAUSE IT INTERFERES WITH ABSORPTION OF FAT SOLUBLE VITAMINS ( ADEK)

HEARTBURN = REFLUX OF STOMACH CONTENT INTO THE ESOPHAGUS DUE TO INCREASED PROGESTERONE WHICH DECREASES GASTRIC MOTILITY

MX: > PATS OF BUTTER BEFORE MEALS

> AVOID FRIED, FATTY FOODS

> BEND AT THE KNEES NOT AT THE WAIST

> TAKE ANTACIDS EX. MILK OF MAGNESIA BUT NEVER SODIUM NHCO3 ( ALKA SELTZER OR BAKING SODA) BECAUSE IT PROMOTES FLUID RETENTION. > DONT LIE DOWN AFTER EATING

PICA = **ABNORMAL CRAVING FOR NON NUTRITIOUS SUBSTANCES. THE MOST COMMON IS CRAVING FOR ICE CUBES. THERE COULD ALSO BE CRAVING FOR PAPER, ETC., **OFTEN ACCOMPANIES IRON DEFICIENCY ANEMIA **ENCOURAGE TO TAKE IRON SUPPLEMENTS

MUSCULOSKELETAL SYSTEM

GRADUAL SOFTENING OF PELVIC LIGAMENTS AND JOINTS TO FACILITATE PASSAGE OF THE BABY. ( RELAXIN) LORDOSIS= FORWARD CURVATURE OF THE LUMBER SPINE . THE PRIDE OF PREGNANCY
LEG CRAMPS ALSO KNOWN AS CHARLEY HORSE MAY OCCUR FROM AN IMBALANCE OF CALCIUM / PHOSPHORUS RATIO IN THE BODY AND FROM PRESSURE OF THE UTERUS ON LOWER EXTREMITIES; FATIGUE; CHILLS BACK PAINS RELIEVED BY WEARING LOW HEELED SHOES

MANAGEMENT: **FREQUENT REST PERIODS WITH FEET ELEVATED **WEAR WARM, COMFORTABLE CLOTHING **INCREASE CALCIUM INTAKE (CALCIUM TABLETS AND DIET)

**DO NOT MASSAGE= BLOOD CLOTS CAN CAUSE EMBOLISM

Nausea and vomiting (morning sickness) related to altered hormone levels and metabolic changes; advise small snacks of dry crackers before arising, small feedings of bland food, milk Urinary frequency and urgency without dysuria; fluid intake should not be restricted Increased vaginal discharge; manage with good hygiene (but no douching) and loosefitting cotton underwear; report signs or symptoms of vaginitis

204

Breast soreness due to hormonal changes; suggest wearing a well-fitting, supportive brassiere Headache due to tension from emotional and physical stresses at any time during pregnancy; provide reassurance, suggest relaxation techniques; inform patient to report persistent and/or severe episodes

205

Heartburn may be related to tension and vomiting in early pregnancy, progesterone-induced decreased motility and relaxation of the cardiac sphincter; displacement of the stomach by the growing uterus; encourage small, frequent meals and discourage overeating, ingesting fried/fatty foods, lying down soon after eating, avoid use of sodium bicarbonate (would interfere with sodium balance) 206 MLNG CELESTE, RN, MD

Constipation related to progesterone-induced hypoperistalsis, compression/displacement of the bowel by the enlarging uterus, poor food choices, lack of fluids, and/or iron supplementation; advise bulk foods, fruits and vegetables, exercise, and generous fluid intake; avoid laxatives

Hemorrhoids due to pelvic congestion related to pressure from enlarged uterus; suggest regulation of bowel habits, gentle reinsertion into rectum with use of lubricant, relief measures, e.g., ice packs, topical ointments, sitz baths, lying down with legs elevated

207

MLNG CELESTE, RN, MD

Uterine contractions (Braxton-Hicks) due to tension on the round ligaments as a result of displacement of the uterus; instruct patient to rest, change position or activity Backache due to increased spinal curvature; educate the patient on the importance of good posture Faintness related to vasomotor lability or postural hypotension; instruct the patient to use slow, deliberate movements when rising, avoid prolonged standing and warm, stuffy environments; elastic hose may be needed

208

MLNG CELESTE, RN, MD

Leg cramps related to pressure on the nerves supplying the lower extremities aggravated by poor peripheral circulation or fatigue; instruct the patient to increase calcium and decrease phosphorus intake; encourage dorsiflexion of feet

Ankle edema related to decreased venous return from lower extremities, instruct the patient to avoid wearing anything that constricts blood flow, elevate legs when sitting or resting, and dorsiflex feet when sitting or standing for any length of time; medical management if edema persists in AM, is pitting, involves the face, or associated with elevated BP, proteinuria, persistent headaches
209 MLNG CELESTE, RN, MD

Varicosities of extremities or vulva related to uterine compression of venous return, increased vein wall distensibility from progesterone-initiated relaxation, or inherited tendency; suggest elevating legs frequently, avoid sitting with legs crossed, standing/sitting for long periods of time, or wearing constrictive clothing; support/elastic stockings may be helpful.

210

DISCOMFORTS OF PREGNANCY Assessment Nursing Considerations May occur any time of day Nausea and vomiting (morning Eat dry crackers on arising sickness) Eat small, frequent meals Bulk foods, fiber Constipation, hemorrhoids Generous fluid intake Increase calcium intake Leg cramps Flex feet, local heat Well-fitting bra Breast soreness Bra may be worn at night Emphasize posture Careful lifting Backache Good shoes Small, frequent meals Antacids avoid those containing phosphorous Heartburn Decrease amount of fatty and salty foods Slow, deliberate movements Support stockings Vena cava or supine hypotensive syndrome Turn on left side Kegel exercises Decrease fluids before bed Report signs of infection

Dizziness Vertigo, light-headedness Urinary frequency

First trimester ACCEPTING THE PREGNANCYI am pregnant maternal ambivalence, even in planned pregnancy, is usual; there may be some anticipation and concern related to fears and fantasies about the pregnancy The fetus is an unidentified concept with great future implications but without tangible evidence of reality. Implication: when giving health teachings, be sure to emphasize the bodily changes in pregnancy.

ACCEPTING THE BABY as a separate individual I am going to have a baby quickening by 20 weeks can help a woman realize that the fetus inside her womb is a real & separate individual to care for. She begins to fantasize about the childs sex & appearance

PREPARING FOR DELIVERY AND PARENTHOOD I am going to be a mother possible new fears related to labor and delivery and fantasies about the appearance of the baby; Woman begins to plan about the birth of the baby. She selects a baby layatte, choose names for her baby, make plans on how the baby will be fed, where the baby will sleep at home etc.

215

PATERNAL REACTIONS TO PREGNANCY: A. FIRST TRIMESTER = AMBIVALENCE & ANXIETY ABOUT ROLE CHANGE; CONCERN FOR IDENTIFICATION WITH MOTHERS DISCOMFORTS ( COUVADE SYNDROME)

B. SECOND TRIMESTER = INCREASED CONFIDENCE & INTEREST IN MOTHERS CARE; DIFFICULTY RELATING TO FETUS; JEALOUSY

PRENATAL CARE ( ANTEPARTUM CARE) - Refers to the health care given to a woman & her family during pregnancy. The primary goal is to provide maximum health to expectant mothers & their babies. 3 PHASES:

1. PRE-CONSULTATION = HISTORY TAKING, FAMILY, MEDICAL, OB HISTORY)

2. CONSULTATION = PHYSICAL ASSESSMENT 3. POST CONSULTATION = HEALTH TEACHINGS

COMPONENTS OF PRE NATAL VISIT

1.PRE- CONSULTATION PHASE: History Taking

PERSONAL DATA: AGE, SEX, CIVIL STATUS, WEIGHT, HEIGHT 1. AGE : UNDER 17 OR ABOVE 35 (GREATER RISK IF OVER 40) ** PREGNANT ADOLESCENTS HAVE A HIGHER INCIDENCE OF PREMATURITY, PIH, CEPHALOPELVIC DISPROPORTION, POOR NUTRITION & INADEQUATE ANTEPARTAL CARE. ** WOMEN OVER 35 YEARS OLD ARE AT RISK FOR CHROMOSOMAL DISORDERS IN INFANTS, PIH & CESARIAN DELIVERY.

OBSTETRICAL DATA: MENSTRUAL HISTORY: INCLUDES MENARCHE, LENGTH & REGULARITY OF MENSES, INTERVAL BETWEEN PERIODS, AMOUNT OF FLOW, DYSMENORRHEA TERMINOLOGIES:

GRAVIDA = THE NUMBER OF PREGNANCIES REGARDLESS OF DURATION OR OUTCOME

PARA = PAST PREGNANCIES RESULTING IN VIABLE FETUS ( 20 WEEKS) WHETHER BORN DEAD OR ALIVE. ( TWINS, TRIPLETS ETC. CONSIDERED AS ONE).

T=

NUMBER OF FULL TERM BIRTHS

P=
A= L= M=

NUMBER OF PREMATURE BIRTHS

NUMBER OF ABORTIONS NUMBER OF LIVING CHILDREN MULTIPLE PREGNANCIES

PRIMIGRAVIDA = A WOMAN WHO IS PREGNANT FOR THE FIRST TIME PRIMIPARA = A WOMAN WHO HAS DELIVERED A VIABLE LIVE OR DEAD CHILD

MULTIGRAVIDA = A WOMAN WHO HAS HAD 2 OR MORE PREGNANCIES

NULLIGRAVIDA = A WOMAN WHO HAS NEVER BEEN & IS NOT CURRENTLY PREGNANT

NULLIPARA A WOMAN WHO HAS NEVER DELIVERED A FETUS THAT REACHED THE AGE OF VIABILITY. SUCH WOMAN MAY OR MAY NOT HAVE BEEN PREGNANT BEFORE.
MULTIPARA A WOMAN WHO HAS COMPLETED TWO OR MORE PREGNANCIES TO THE AGE OF VIABILITY.

EX: Utilize the GTPAL system to classify a woman who is currently 8 months pregnant. This is her fourth pregnancy. She delivered 1 baby vaginally at 26 weeks who died, experienced a miscarriage, and has one living child who was delivered at 38 weeks gestation. a.3 2 1 2 1 b.4 2 2 1 1 c.3 2 1 1 1 d.4 1 1 1 1

EX: A nurse is collecting the data during an admission assessment of Manilyn, a client who is pregnant with twins. She has healthy 4 years old child that was delivered 38 weeks and tell the nurse that she does not have a history of abortion or fetal demise. The nurse would document the GP(TPAL) for this client as a. G3P1 ( 2-0-0-1) b. G2P2 (0-1-0-1) c. G2P1 (1-0-0-1) d. G2P2 ( 2-0-0-2)

A woman who has had term twins, then 1 preterm infant & is now pregnant again is classified as: G3 P 21031 ( GTPALM)

Term infant an infant born between 38 and 42 weeks of gestation Preterm an infant born before 38 weeks Post term an infant born after 42 weeks Abortion pregnancy that terminates before the period of viability (20 wks) Live birth a live birth is recorded when an infant born shows sign of life

Stillbirth infant born without signs of life Early neonatal Death death of newborn within 7 days after birth Late neonatal Death death of newborn between 7 to 29 days after birth Low birth weight < 2500 grams Normal Birth weight 2500 4000 grams Large birth weight - > 4000 grams Parturient a woman in labor Puerpera a woman who just delivered (within six weeks after delivery)

MATERNAL MORTALITY RATE NUMBER OF DEATHS THAT OCCURRED DUE TO COMPLICATIONS OF PREGNANCY, LABOR & PUERPERIUM PER 10,000 LIVE BIRTHS. THE THREE MAJOR CAUSES OF MATERNAL MORTALITY ARE: 1. HEMORRHAGE 2. INFECTION

3. PREGNANCY INDUCED HYPERTENSION

INFANT MORTALITY RATE NUMBER OF INFANT DEATHS DURING THE FIRST 12 MONTHS OF LIFE PER 1000 LIVE BIRTHS FERTILITY RATE NUMBER OF LIVE BIRTHS PER 1000 FEMALE POPULATION AGED 15 TO 44 YEARS

2. CONSULTATION PHASE: Physical

assessment 1. Initial visit complete physical exam *Weight, Height & VS are obtained to

establish a baseline for future comparisons.

Determine Goodels, Hegars and Chadwick signs

228

Initially and at routine visits, urine dipstick for glucose, protein (pregnancy induced hypertension and UTI), CBC, rubella IgG antibody Maternal serum alpha-fetoprotein (AFP) at 16-18 wk to identify risk of neural tube defect in fetus Glucose screening between 24-28 wk to detect gestational diabetes Repeat CBC at 24 28 wk Rh antibody titers for Rh(-) woman at 24, 28, 32, and 40 wks ultrasound
229

Urinalysis

1.Collect urinary specimen by midstream or clean catch technique 2. Benedicts test to detect glycosuria 3. Heat & acetic acid to detect proteinuria 4. Urinalysis in the first trimester is also performed to detect asymptomatic bacteuria. Bacteuria can lead to abortion early in pregnancy & can cause premature labor late in pregnancy.

Blood Tests Hematocrit & Hemoglobin count at initial clinic visit & repeated at 28-32 weeks to detect anemia.
Normal Hemoglobin level is between 12-16 mg/dl
Normal Hematocrit count is between 37-47%

VDRL and Kahn & Wassaerman test to detect Syphilis Gonorrhea Culture Rubella Antibody Titer to detect degree of protection against german measles. A test result of 1:8 or less indicates that the mother is at risk of acquiring the infection during pregnancy. A titer more than 1:8 means that the mother has immunity against german measles

 Fetal

movement Fetal heart rate Ultrasound Nonstress Test

Maternal serum alphafetoprotein Triple screening (AFP, estriol and hCG) Chorionic villi sampling Amniocentesis Percutaneous umbilical blood sampling

Biophysical

profile
233

Fetal movement that can be felt by the mother : QUICKENING begins at approximately 18 20 weeks of pregnancy; peaks at 28-38 weeks Primigravid- quickening:20 weeks ( 5 months) Multigravid- 16 weeks ( 4 months) Ask the mother to observe fetal movement.

234

Is a daily recording of fetal movements to assess active & passive fetal states in pregnancy A non invasive test 3 or more movements in 1 hour is considered normal 2 or less movements in 1 hour must be reported & maybe scheduled for NST

235

Measures the response of fetal heart rate to fetal movement Determines fetal wellbeing Performed to assess placental function and oxygenation
236

An external ultrasound transducer and the tocodynamometer are applied to the mother and a tracing of at least 20 minutes duration is obtained so that the FHR and the uterine activity can be observed. Obtain baseline blood pressure and monitor blood pressure frequently. Position mother in semi-fowlers or side- lying position or left lateral position to avoid vena cava compression. The mother may be asked to press a button every time she feels fetal movement; the monitor records a mark at each point of fetal movement, which is used as a reference point to assess FHR response.

237

RESULTS OF NST: REACTIVE NONSTRESS TEST:Normal/Negative - indicates a healthy fetus - requires 2 or more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period.

NONREACTIVE NONSTRESS TEST: Abnormal -No accelerations or accelerations of less than 15 bpm or lasting less than 15 seconds in duration occur in a 40 minute observation.
UNSATISFACTORY The result cannot be interpreted because of the poor quality of the FHR tracing.
238

Assesses placental oxygenation and function Determines fetal ability to tolerate labor and determines fetal well-being Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions.

239

External fetal monitor is applied to the mother, and a 20 to 30 minute baseline strip is recorded. The uterus is stimulated to contract by the administration of a dilute dose of oxytocin or by having the mother use nipple stimulation until 3 palpable contractions with a duration of 40 seconds or more in a 10 minute period have been achieved. Frequent maternal BP readings are done, and the mother is monitored closely while increasing doses of oxytocin are given.
240

RESULTS OF CST: NEGATIVE CST/ NORMAL - no late or variable decelerations of FHR

POSITIVE CST/ ABNORMAL - late or variable decelerations of FHR with 50% or more of the contractions in the absence of hyperstimulation of the uterus.

EQUIVOCAL with decelerations but with less than 50% of the contractions, or the uterine activity shows a hyperstimulated uterus.
UNSATISFACTORY adequate uterine contractions cannot be achieved, or the FHR tracing is not of sufficient quality for adequate interpretation.
241

Fetal Heart Rate Patterns Tachycardia (>160 bpm)

Indicative of
Maternal

Intervention Depends on the cause

Place

or fetal infection Fetal hypoxia (ominous sign)

Fetal

Bradycardia (<120 bpm)

hypoxia or stress Maternal hypotension after epidural initiation

Head

client on her left side Increase fluids to counteract hypotension Stop oxytocin (Pitocin) if in use
None required

Early deceleration (deceleration begins and ends with uterine contraction) Late deceleration (HR decreases after peak of contraction and recovers after contraction ends)

compression :not ominous Vagal stimulation

Fetal

stress and hypoxia Deficient placental perfusion Supine position Maternal hypotension Uterine hyperstimulation
Cord

Change

maternal position Correct hypotension Increase IV fluid rate as ordered Discontinue oxytocin Administer oxygen as ordered
Change

Variable deceleration (transient decrease in HR anytime during contraction Decreased variability

compression Hypoxia or hypercarbia

Fetal

maternal position Administer Oxygen Depends on the cause

sleep cycle Depressant drugs Hypoxia CNS anomalies

Variability beat-to-beat fluctuations; measured by internal EFM only a. Normal (6-25 BPM) significant indicator of fetal well-being b. Absent (0-2 BPM) or decreased (3-5 BPM) may be associated with fetal sleep state, fetal prematurity, reaction to drugs, congenital anomalies, hypoxia, acidosis; if persists for more than 30 min is indicator of fetal distress c. Increased (>25 BPM) significance is not known d. Loss of the baseline (beat-to-beat variation) or smoothing out of the baseline is often prelude to infant death

Periodic changes 1. Accelerations rise above baseline followed by a return; usually in response to fetal movement of contractions 2. Decelerations fall below baseline followed by a return a.Early occurs before peak contraction; most often uniform mirror image of contraction on tracing; associated with head compression, commonly in second stage with pushing b.Late onset after the peak with slow return to baseline; indicative of fetal hypoxia because of deficient placental perfusion c.Variable deceleration transient U/V/M-shaped reduction occurring at any time

before, during, or after contraction; indicative of cord compression, which may be relieved by change in mothers position; ominous if repetitive, prolonged, severe, or has slow return to baseline Nursing interventions: >None for early decelerations >For late decelerations (at the first sign of abnormal tracing) position mother left side-lying (if no change, move to other side, Trendelenburg or knee/chest position); administer oxygen by mask, start IV or increase flow rate, stop oxytocin if appropriate; if the pattern persists, fetal scalp blood sampling for acidosis (pH >7.25 is normal, 7.20-7.24 is considered preacidotic repeat in 10-15 min; 7.2 or less indicates serious acidosis; prepare for cesarean section

FHR should be 120-160 beats per minute Can be heard with a Doppler : 10 12th week of pregnancy ( 3 months) Fetoscope: 18-20 weeks ( 4 months) Stethoscope: 20 weeks ( 5 months)
247

Response of sound waves against objects Allows visualization of the uterine content Transabdominal UTZ - full bladder - client lies on her back Transvaginal UTZ - probe is inserted in the vagina - lithotomy position - empty bladder ( UZ is Best performed bet 8-18 weeks) 249

Diagnose pregnancy as early as 6 weeks Confirm the presence, size and location of the placenta and amniotic fluid Establish that the fetus is growing and has no gross defects (eg, hydrocephalus, anencephaly, spinal cord, heart, kidney and bladder defects) Establish the presentation and position of the fetus Predict maturity by measurement of the biparietal diameter (BPD) discover complications of pregnancy / fetal anomalies

250

Can assess fetal age by getting the fetal crown to- rump measurement

Nursing Interventions: Pre-procedure: Drink 1 glass of water every 15 minutes for 90 minutes Place a towel under the patients right buttock to tip her body slightly so that the uterus will roll away from the vena cava thus preventing supine hypotension syndrome

Ultrasound is used to predict fetal maturity by measuring the biparietal diameter ( side to side or transverse diameter) of the fetal head. 8.5 cm or greater = infant weighs more than 2500g ( 5.5lbs) 8.5 cm bi parietal diameter indicates fetal age of 40 weeks ( term)

amniotic fluid is aspirated by a needle inserted through the abdominal and uterine walls; indicated early in pregnancy (14-17 wk) to detect inborn errors of metabolism, chromosomal abnormalities, open NTD (neural tube defect); sex-linked disorders after 28 wk; determine lung maturity = 15 ML OF FLUID IS ASPIRATED Indicated for pregnant women 35 years and older; couples who already have had a child with a genetic disorder; one or both parents affected with a genetic disorder; mothers who are carriers for X-linked disorders An ultrasound is performed to determine a safe site for the needle to enter. Watch out for cramping, leakage o fluid, minor irritation around entry site & slight risk for miscarriage.

254

Prior to the procedure, the patients bladder should be emptied if AOG is more than 20 weeks Post procedure, monitor for signs and symptoms of hemorrhage, labor, premature separation of placenta, fetal distress, amniotic fluid embolism, infection, inadvertent injury to maternal intestines/bladder or fetus; RhoGam is indicated for Rh(-) mothers
256

 transcervical aspiration of chorionic villi that allows for first trimester (8-12 wk) diagnosing of genetic disorders comparable to amniocentesis (except for NTD because no amniotic fluid is retrieved during the procedure ) Pre-procedure: there should be full bladder; ultrasound is used as in amniocentesis; Post procedure: precautions as for amniocentesis

257

 serial 24-h maternal urine samples or serum specimens to determine fetoplacental status; falling levels usually indicate deterioration

258

 second- and third-trimester method to aspirate cord blood (location identified by ultrasound) to test for genetic conditions, chromosomal abnormalities, fetal infections, hemolytic or hematological disorders

259

 important components of surfactant, a

phosphoprotein that the alveoli begin to form at about the 22nd to 24th weeks of pregnancy _ it lowers surface tension of the lungs that facilitates extrauterine expiration - Prevents lung collapse - Determines fetal lung maturity

260

Assesses 4 to 6 parameters (fetal breathing movement, fetal body movement, fetal tone, amniotic fluid volume, placental grading, and fetal heart reactivity/ reactive NST) Each item has a potential for scoring a 2; 12 highest possible score BPS 8 10: fetus is doing well BPS 6: fetus is in jeopardy; worrisome BPS 4 or less is Ominous. The doctor may decide to deliver the baby if the score is 6 or below

261

Criteria in BPS: 1. Fetal Breathing Movements ( FBM)

Normal: At least one episode of FBM of at least 30 sec duration in 30 mins of observation Abnormal: Absent FBM o no episode of more than 30 sec in 30 mins Normal: at least 3 discrete body/limb movements in 30 mins w/ episodes of activity Abnormal: 2 or fewer episodes of body/limb movements in 30 mins

2. Gross Body Movement

3. Fetal Tone

Normal: the fetus must extend and then flex the extremities or spine at least once in 30 minutes

4. Amniotic fluid volume Normal: a pocket of amniotic fluid measuring more than 1 cm in vertical diameter must be present 5. Placental grade

Normal: grade 3 ( grading is based on structure and amount of calcium present)

Determines the amount of calcium deposits on the base of the placenta 0 = 12 to 24 weeks 1 = 30 to 32 weeks 2 = 36 weeks 3 = 38 weeks ( mature)

Involves drawing a small amount of BLOOD from the mother to check for the level of alphafetoprotein AFP is produced by the fetal liver & is excreted thru placenta into the mothers blood High amount: Neural Tube defect ( NTD) such as spina bifida (open spine)or anencephaly ( absence of brain) Low amount: Indicative of Trisomy 21 Best results are obtained if taken between 16-18 wks NV 2.5 MOM multiples of the mean

TESTS DONE: Between 16-18 weeks

Maternal serum Alphafetoprotein Diabetic screening for all pregnant women Repeat Hgb & Hct Repeat Antibody for unsensitized Rh negative women Ultrasound Testing for STD

Between 26-28 weeks

Between 32-36 weeks

BASELINE VITAL SIGNS = TEMPERATURE, PULSE AND RESPIRATORY RATES ARE IMPORTANT ESPECIALLY DURING THE INITIAL PHASE OF THE PRENATAL VISIT . BUT CERTAINLY MORE IMPORTANT ARE THE WEIGHT & BLOOD PRESSURE AS BASELINE DATA TO DETERMINE ANY SIGNIFICANT INCREASE. BP SLIGHT DECREASE IN THE SYSTOLIC & DIASTOLIC BP ON THE 1ST TRIMESTER, LOWEST IN THE 2ND TRI; & RETURNS TO PREPREGNANCY LEVELS ON THE 3RD TRI
- HIGHEST READING AT SITTING POSITION, LOWEST AT LLP

WEIGHT
*DURING THE FIRST TRIMESTER, WEIGHT GAIN OF 1.5-3LBS.( 1lb per month or 0.4 kg)

*ON THE 2ND AND 3RD TRIMESTERS, WEIGHT GAIN OF 10-12 POUNDS PER TRIMESTER IS RECOMMENDED.( 1 lb per week)( a trimester pattern of 3-12-12)
*TOTAL ALLOWABLE WEIGHT GAIN DURING THE ENTIRE PERIOD OF PREGNANCY IS 25-35 LBS.

( 11.2 -15.9 KGS.). MORE THAN 35 LBS OF WEIGHT GAIN IS A DANGER SIGN = POSSIBLE PREECLAMPSIA.

Women who are underweight coming to pregnancy should gain slightly more weight than the average woman ( 0.5kg/mo or 30 40 lbs Adolescent 5 lbs more than the adult wt gain Obese ( 0.3kg or 15 20 lbs Twin 40 to 45 lbs

DISTRIBUTION OF WEIGHT GAIN DURING PREGNANCY: FETUS PLACENTA AMNIOTIC FLUID INCREASED WT. OF UTERUS INCREASED BLOOD VOLUME INCREASED WT. OF THE BREASTS 7 LBS 1 LB 11/2 LBS 2 LBS 1 LB 11/2-3 LBS

WT. OF ADDITIONAL FLUID

FAT & FLUID ACCUMULATION

2 LBS
4-6 LBS.

TOTAL

25 LBS

Schedule of clinic visits Bathing Breast care Perineal Hygiene Dental care Exercises Clothing Traveling Employment Sexual relations Immunization

A.PRENATAL CARE: SCHEDULE OF PRENATAL VISIT:

A. ONCE EVERY 4 WEEKS , UP TO 32 WEEKS

B. EVERY 2 WEEKS FROM 32 37 WEEKS

( MORE FREQUENTLY IF PROBLEM EXISTS)

C. EVERY WEEK FROM 37 40 WEEKS *** To monitor VS, Weight, FHT, Fundal height and Outline

BATHING:
DUE TO INCREASED PERSPIRATION , THE PREGNANT WOMAN IS ENCOURAGED TO HAVE A DAILY BATH TO KEEP HER FRESH & CLEAN. 2. TUB BATH IS DISCOURAGED BECAUSE ALTERATION IN THE WOMANS BALANCE MAKES GETTING IN & OUT OF THE BATH TUB DIFFICULT, SHE MIGHT SLIP & FALL & HURT HERSELF. 3. SWIMMING IS OK BUT NO DIVING.

PERINEAL HYGIENE: DOUCHING IS CONTRAINDICATED DURING PREGNANCY BECAUSE THE FORCE OF THE IRRIGATING FLUID COULD CAUSE IT TO ENTER THE CERVIX & INTRODUCE INFECTION. ALSO DOUCHING COULD ALTER THE pH OF THE VAGINA, LEADING TO AN INCREASED RISK OF BACTERIAL GROWTH.

BREAST CARE: 1. WELL FITTING & LARGER SIZED BRASSIERE ( WIDE STRAPS & DEEP CUPS TO PREVENT LOSS OF BREAST TONE.) 2. WASH BREAST WITH WATER ONLY. NO SOAPS OR ALCOHOL SHOULD BE USED AS THESE CAUSES DRYING & CRACKING. DRY NIPPLES THOROUGHLY

Dental Care: Gingival tissue tend to hypertrophy during pregnancy. Routine check ups, extensive dental surgery is avoided Dressing:

a pregnant woman should avoid the use of garters, extremely firm girdles w/ panty legs, & knee high stockings because these may impede lower extremity cirulation

**TERATOGENICITY OF CIGARETTES = ( associated w/ infertility in women) CAUSES VASOCONSTRICTION LEADING TO DECREASED BLOOD FLOW TO THE PLACENTA & UTERUS WHICH IN TURN DIMINISHES O2 SUPPLY TO THE FETUS. FETAL HYPOXIA LEADS TO LOW BIRTH WEIGHT BABIES AND THEREFORE IS CONTRAINDICATED DURING PREGNANCY. **SLEEP = NEEDS INCREASE TO PROMOTE OPTIMAL FETAL GROWTH

** EMPLOYMENT = AS LONG AS THE JOB DOES NOT ENTAIL HANDLING TOXIC SUBSTANCES OR LIFTING HEAVY OBJECTS , OR EXCESSIVE EMOTIONAL STRAIN, THERE IS NO CONTRAINDICATION TO WORKING. ADVISE PREGNANT WOMEN TO WALK ABOUT EVERY FEW HOURS OF HER WORKDAY DURING LONG PERIODS OF STANDING OR SITTING TO PROMOTE CIRCULATION THEREBY MINIMIZING VARICOSE VEINS.

** TRAVELLING = NO TRAVEL RESTRICTIONS BUT POSTPONE A TRIP DURING THE LAST TRIMESTER. ON LONG RIDES , 15-20 MINUTE REST PERIODS EVERY 2-3 HOURS TO WALK ABOUT OR EMPTY THE BLADDER IS ADVISABLE.
** EXERCISE = SHOULD BE DONE IN MODERATION; SHOULD BE INDIVIDUALIZED: ACCORDING TO AGE, PHYSICAL CONDITION, CUSTOMARY AMOUNT OF EXERCISE ( SWIMMING OR TENNIS) NOT CONTRAINDICATED UNLESS DONE FORE THE FIRST TIME ; & STAGE OF PREGNANCY

**TERATOGENICITY OF ALCOHOL = ALCOHOL HAS NOW BEEN FIRMLY ISOLATED AS A TERATOGEN. FETUSES CANNOT REMOVE THE BREAKDOWN PRODUCTS OF ALCOHOL FROM THEIR BODY. THE LARGE BUILD UP OF THESE LEADS TO VIT B DEFICIENCY & ACCOMPANYING NEUROLOGIC DAMAGE. (pregnant women should be screened for alcohol use because an infant born with fetal alcohol syndrome is not only small for gestational age but can be cognitively challenged. ( short palpebral fissures, thin upper lip, upturned nose)

.
**DRUGS= DANGEROUS TO FETUS ESPECIALLY DURING THE FIRST TRIMESTER WHEN THE PLACENTAL BARRIER IS STILL INCOMPLETE AND THE DIFFERENT BODY ORGANS ARE DEVELOPING. ARE TERATOGENIC (CAN CAUSE CONGENITAL DEFECTS)(AND THEREFORE, CONTRAINDICATED UNLESS PRESCRIBED BY THE DOCTOR)

Drugs
Androgen, Estrogen Progesterone Thalidomide Anticonvulsant Lithium Tetracycline Vitamin K Salicylates ( aspirin) Streptomycin Vitamin A Barbiturates

Teratogenic Effects
- Musculinization of female infants - Phocomelia, cardiac & lung defect - cleft lip & palate; CHD - CHD - yellow staining of teeth, inhibit bone growth - Hyperbilirubinemia - neonatal bleeding,decreased IUG - Nerve defects - CNS defects - Bleeding disorders

SEXUAL RELATIONS: DESIRE:

CHANGES IN SEXUAL

A.FIRST TRIMESTER = SEXUAL DESIRE IS DECREASED AS CAUSED BY NAUSEA, FATIGUE & SLEEPINESS.

B. SECOND TRIMESTER = SEXUAL DESIRE IS INCREASED DUE TO PELVIC CONGESTION & SENSE OF WELL BEING.
C. THIRD TRIMESTER = SEXUAL DESIRE IS DECREASED DUE TO FATIGUE & PHYSICAL BULKINESS

** SEXUAL INTERCOURSE IS ALLOWED UNTIL THE LAST 6 WEEKS OF PREGNANCY ( BECAUSE IT HAS BEEN FOUND OUT THAT THERE IS INCREASED INCIDENCE OF POSTPARTUM INFECTION IN WOMEN WHO ENGAGE IN SEX DURING THE LAST 6 WEEKS) AS LONG AS THERE ARE NO CONTRAINDICATIONS LIKE THE FOLLOWING: 1. BLEEDING 2. INCOMPETENT CERVICAL OS 3. DEEPLY ENGAGED PRESENTING PART 4. RUPTURED BOW

** SEXUAL INTERCOURSE SHOULD BE DONE WITH THE WOMAN IN A COMFORTABLE POSITION: 1. SIDE LYING 2. WOMAN SUPERIOR WOMAN ON TOP

** Hyperthermia detrimental to growth

because it interferes with cell metabolism. Pregnant women should avoid use of saunas, hot tubs, tanning beds or from a work environment next to a furnace such as in welding or steel making. Maternal fever in early pregnancy should be reported

An emotionally disturbed pregnancy, one filled with emotional worry or anxiety beyond the usual amount, could produce physiologic changes through its effect on the sympathetic division of the autonomic nervous system. The primary changes could include constriction of the peripheral blood vessels. If the anxiety is prolonged, the constriction of uterine vessels ( uterus is a peripheral organ) could interfere with the blood & nutrient supply to a fetus. Extreme stress, illness or death of ones partner, difficulty w/ relatives, marital discord & illness or death of another child are examples of stressful situations Secure counseling is important

TT IMMUNIZATION:
> TT1 GIVEN ANYTIME DURING PREGNANCY

> TT2 ONE MONTH AFTER TT1 ( 3 YEARS PROTECTION) > TT3 SIX MONTHS AFTER TT2 ( 5 YEARS PROTECTION)
> TT4 ONE YEAR AFTER TT3 ( 10 YRS) > TT5 ONE YEAR AFTER TT4 OR NEXT PREGNANCY ( LIFETIME PROTECTION)

1.

a.

b.

c. d.

Nutritional Teaching for the pregnant client should emphasize: Eating 3 meals a day or more frequent small meals Include snacks of fruit, cheese and milk 2-3X a day Six (6) glasses (8oz) a day fluid intake Eat a variety of foods, including the minimum from the RDA for pregnancy and lactation

2. Recommended Daily Allowance (RDA) for Pregnancy and Lactation !. Energy Requirement for Pregnancy * 2100 to 2200 cal ( 1st trimester) * 2100 to 2200 cal + 300 cal= 2400 to 2500 cal/day ( 2nd trimester) * 2100 to 2200 cal+300 cal= 2400 to 2500 cal/day ( 3rd trimester) !!. Energy Requirement for Lactation * 2,200 cal+ 500 cal = 2700 cal/day

NUTRITION = MOST IMPORTANT ASPECT OF POST CONSULTATION FOOD SOURCES: ** PROTEIN RICH FOODS = MEAT, FISH, EGGS, MILK, POULTRY, CHEESE, BEANS, MONGO ** VIT. A = EGGS, CARROTS, SQUASH, CHEESE, BEANS, VEGETABLES ** VIT. D = FISH, LIVER, EGGS, MILK ( EXCESS VIT.D DURING PREGNANCY CAN LEAD TO FETAL CARDIAC PROBLEMS) **VITAMIN E = GREEN LEAFY VEGETABLES, FISH

**VITAMIN C= TOMATOES, GUAVA, PAPAYA **VITAMIN B= PROTEIN RICH FOODS **CALCIUM/PHOSPHORUS=MILK, CHEESE **IRON= ESPECIALLY IMPORTANT DURING THE LAST TRIMESTER WHEN THE PREGNANT WOMAN IS GOING TO TRANSFER HER IRON STORES FROM HERSELF TO HER FETUS SO THAT THE BABY HAS ENOUGH IRON STORES DURING THE 1ST 3 MONTHS OF LIFE WHEN ALL HE TAKES IS MILK(WHICH IS DEFICIENT IN IRON). IRON HAS A VERY LOW ABSORPTION RATE: ONLY 10% OF THE IRON INTAKE CAN BE ABSORBED BY THE BODY. THUS, FOR OPTIMUM ABSORPTION, GIVE VITAMIN C.

IRON SHOULD BE GIVEN AFTER MEALS BECAUSE IT IS IRRITATING TO THE GASTRIC MUCOSA. SOURCES: LIVER AND OTHER INTERNAL ORGANS, CAMOTE TOPS, KANGKONG, EGG YOLK, AMPALAYA, MALUNGGAY, SALUYOT. **MALNUTRITION DURING PREGNANCY CAN RESULT IN PREMATURITY, PREECLAMPSIA, ABORTION, LOW BIRTH WEIGHT BABIES, CONGENITAL DEFECTS OR EVEN STILL BIRTHS.

** FOLIC ACID TO PREVENT NEURAL TUBE DEFECTS ( SPINA BIFIDA, MENINGOCOELE ) SOURCES: ** GREEN LEAFY VEGETABLES ** FRUITS ( oranges)

** liver, legumes, nuts

** RDA FOR SALT IN A PREGNANT WOMAN IS 3g/DAY BECAUSE OF INC IN BLOOD VOLUME TO MAINTAIN F & E BALANCE.

Calories 300 kcal/d; may need adjustment for prepregnant under/overweight There should be no attempt at weight reduction during pregnancy Carbohydrates needed to prevent unsuitable use of fats/proteins for added energy needs; important to avoid empty calorie sources

e. Iron to a total of 30 mg/d of elemental iron; usually requires supplement

f. Calcium to 1,200mg; best obtained from dairy products; if milk is disliked or poorly tolerated, calcium supplement may be necessary g. Sodium should not be restricted without serious indication; excess should be discouraged g. Phosphorus for the devt of fetal bones & teeth. 1200mg 3. 24-h recall/diet diaries may be used to evaluate highrisk woman

** THE PROVISION OF PRENATAL CARE IS THE PRIMARY FACTOR IN THE IMPROVEMENT OF MATERNAL MORBIDITY & MORTALITY STATISTICS.

IMPORTANT ESTIMATES
1. NAEGELES RULE = CALCULATION OF EXPECTED DATE OF CONFINEMENT ( EDC ) FORMULA: COUNT BACK 3 MONTHS FROM THE LAST DAY OF THE MENSTRUAL PERIOD (LMP) THEN ADD 7 DAYS PLUS 1 YEAR. EXAMPLE: LMP APRIL 22, 1995 -3 +7 +1

JAN

29, 1996

LAST MENSTRUAL PERIOD ( LMP ) counted from first day of the last menses

COMPUTATION OF AGE OF GESTATION Example: LMP: January 1, 2007 Date of consult: August 31, 2007 AOG: Total # of days from LMP up to date of consult 7 January February March April May June July August 31 days 28 31 30 31 30 31 31 Total = 243 days AOG = 243 7 34 to 35 weeks

2. MC DONALDS RULE = ( ESTIMATION OF AOG IN MONTHS & WEEKS BY FUNDIC HEIGHT MEASUREMENT)= FORMULA :
FUNDIC HEIGHT IN CMS X 2/7 OR 8/7 EXAMPLE: FUNDIC HEIGHT IS 21 CMS 21 CMS X 2 =42 42/ 7 = 6 ( AOG IN MONTHS) 6 MONTHS X 4 = 24 ( AOG IN WEEKS)

McDonalds Rule determines during midpregnancy, that the fetus is growing in utero by measuring the fundal (uterine) height

Typically, the distance from the fundus to the symphysis in centimeters is equal to the week of gestation between the 20th and 31st weeks of pregnancy.

Measure from the notch of the symphysis pubis to over the top of the uterine fundus as the woman lies supine. Place the zero line of the tape measure on the anterior border of the symphysis pubis and stretch tape over midline of abdomen to top of fundus. The tape should be brought over the curve of the fundus. The height of the fundus in centimeters equals the number of weeks gestation plus or minus 2. (inaccurate in the 3rd trimester esp after 32 wks) Typical measurements Over the symphysis pubis: 12 wks At the umbilicus: 20 wks At the xiphoid process: 36 wks Rises about 1cm per week; after which it varies

BARTHOLOMEWS RULE = ESTIMATION OF AOG BY THE RELATIVE POSITION OF THE UTERUS (FUNDUS) IN THE ABDOMINAL CAVITY.
12 weeks at the level of the symphysis pubis 16 weeks halfway between symphysis pubis and umbilicus 20weeks at the level of the umbilicus 24 weeks two fingers above umbilicus 30 weeks midway between umbilicus and xiphoid process 36 weeks at the level of xiphoid process 40 weeks two fingers below xiphoid process, drops at 34 weeks level because of lightening

LEOPOLDS MANEUVER

LEOPOLDS MANEUVER

= A SYSTEMATIC METHOD OF OBSERVATION & PALPATION TO DETERMINE THE PRESENTATION OR FETAL LIE, FETAL POSITION, ATTITUDE, & DEGREE OF ENGAGEMENT. THE WOMAN SHOULD BE IN SUPINE POSITION WITH HER KNEES FLEXED SLIGHTLY SO AS TO RELAX THE ABDOMINAL MUSCLES.
** INSTRUCT THE CLIENT TO VOID ** PUT TOWEL UNDER HHEAD & RIGHT HIP TO PREVENT VENA CAVA SYNDROME ** PALPATE WITH WARM HANDS. COLD HANDS CAUSE ABDOMINAL MUSCLES TO CONTRACT.

** USE GENTLE BUT FIRM MOTIONS. PROCEDURE:

1. FIRST MANEUVER = ( DETERMINES THE FETAL PRESENTATION)= FUNDIC GRIP

** FACING THE HEAD PART OF THE CLIENT, PALPATE THE SUPERIOR SURFACE OF THE FUNDUS.DETERMINE CONSISTENCY, SHAPE & MOBILITY. A HARD BALLOTABLE MASS AT THE FUNDUS MEANS THE FETUS IS IN BREECH PRESENTATION.

MARY LOURDES NACEL G. CELESTE, RN, MD

311

2. SECOND MANEUVER = ( DETERMINES THE FETAL BACK)= UMBILICAL GRIP

**MOVE BOTH HANDS TO THE SIDES OF THE MOTHERS ABDOMEN TO DETERMINE WHERE THE FETAL BACK IS FACING. THE LEFT HAND IS LEFT STATIONARY ON THE LEFT SIDE OF THE UTERUS WHILE THE RIGHT HAND PALPATES OPPOSITE SIDE OF THE UTERUS FROM TOP TO BOTTOM. DO ON THE OPPOSITE SIDE.WHERE BACK IS LOCATED, THE FHR IS HEARD LOUDEST.

MARY LOURDES NACEL G. CELESTE, RN, MD

313

3.THIRD MANEUVER =( DETERMINES DEGREE OF ENGAGEMENT)- PAWLICKS GRIP > PALPATE TO DISCOVER THE PART OF THE FETUS AT THE INLET & ITS MOBILITY. GRASP THE LOWER PORTION OF THE ABDOMEN JUST ABOVE THE SYMPHYSIS PUBIS BETWEEN THE THUMB & INDEX FINGER . DETERMINE ANY MOVEMENT & WHETHER THE PART IS FIRM OR SOFT. IF THE PRESENTING PART MOVES UPWARD,SO AN EXAMINING FINGERS CAN BE PRESSED TOGETHER, THE PRESENTING PART IS NOT ENGAGED ( NOT FIRMLY SETTLED INTO THE PELVIS). IF THE PART IS FIRM , IT IS THE HEAD; IF SOFT THEN IT IS IN BREECH POSITION.

MARY LOURDES NACEL G. CELESTE, RN, MD

315

MARY LOURDES NACEL G. CELESTE, RN, MD

316

4. FOURTH MANEUVER = ( DETERMINES FETAL ATTITUDE & DEGREE OF FLEXION OR EXTENSION).NOTE: THIS SHOULD ONLY BE DONE IF THE FETUS IS IN CEPHALIC PRESENTATION. = PELVIC GRIP ** FACING THE FEET PART OF THE PATIENT, PLACE FINGERS ON BOTH SIDES OF THE UTERUS APPROXIMATELY 2 INCHES ABOVE THE INGUINAL CANAL PRESSING DOWNWARD & INWARD IN THE DIRECTION OF THE BIRTH CANAL. ALLOW FINGERS TO BE CARRIED DOWNWARD. IF THE FINGERS OF ONE HAND WILL SLIDE ALONG THE UTERINE CONTOUR & MEET NO

OBSTRUCTION, IT INDICATES NECK OF THE FETAL BACK. THE OTHER HAND WILL MEET AN OBSTRUCTION AN INCH OR SO ABOVE THE LIGAMENT THIS IS THE FETAL BROW. THE POSITION OF THE FETAL BROW SHOULD CORRESPOND TO THE SIDE OF THE UTERUS THAT CONTAINED THE ELBOWS & KNEES OF THE FETUS. IF THE FETUS IS IN A POOR ATTITUDE, THE EXAMINING FINGER WILL MEET AN OBSTRUCTION ON THE SAME SIDE AS THE FETAL BACK, THAT IS, THE FINGERS WILL TOUCH THE HYPEREXTENDED HEAD.

Preparation for Childbirth and Parenting

**

CHILDBIRTH PREPARATION CLASSES = NON PHARMACOLOGIC PAIN REDUCTION DURING LABOR. = TO DECREASE FEAR & ANXIETY

1. THE BRADLEY ( PARTNER COACHED) METHOD ** stresses the important role of the husband during pregnancy, labor and early newborn period **PAIN IS REDUCED BY ABDOMINAL BREATHING
**woman is encouraged to walk during labor

Bradley Method - husband coach although the coach is not necessarily the husband - involves the concept of leading, guiding, supporting, caring & fostering specific skills & confidence. - coaches attend classes & help the woman long before labor begins - the coach serves as a conditioned stimulus using the sound of his or her voice, use of particular words, & repetition of practice. - medications are not encouraged for pain relief. Relaxation is the core component

2. PSYCHOSEXUAL METHOD =
** CONSCIENTIOUS RELAXATION & LEVELS OF PROGRESSIVE BREATHING THAT ENCOURAGES THE WOMAN TO FLOW WITH RATHER THAN STRUGGLE WITH CONTRACTIONS.

3. DICK-READ METHOD
** FEAR LEADS TO TENSION, WHICH LEADS TO PAIN ** RELAXATION TECHNIQUES ** AVOIDANCE OF MEDICINES

Covers: practice of breathing techniques during labor; controlled perception; relaxation of involved muscles; mouthing silently words or songs with rhythmical tapping of fingers; supportive person nearby in a calm environment Use 3 Gate Control Method of pain relief education and relaxation use of imagery and focusing (breathing patterns) conditioned reflex

4. LAMAZE METHOD ** PREVIOUSLY TERMED PSYCHOPROPHYLACTIC METHOD ( MEANING PREVENTING PAIN IN LABOR (PROPHYLAXIS) BY USE OF THE MIND (PSYCHE) ** CONSCIOUS APPLICATION OF CONDITIONED RESPONSES TO STIMULI

** fear, which enhances the perception of pain may diminish or disappear when the woman understands the physiology of labor ** relaxation & specific type of breathing diminish or abolish the pains of labor

LAMAZE METHOD psychoprophylactic childbirth has a rationale based on Pavlovs concept of pain perception & his theory of conditioned reflexes ( the substitution of favorable conditioned reflexes for unfavorable ones) ** woman is taught to replace responses of restlessness, fear & the use of control with more useful activity, exercises that strengthens the abdominal muscles & relax the perineum ** woman is also taught breathing techniques

** one method of control consists of breathing normally while silently mouthing the words to a song & simultaneously tapping the rhythmn w/ fingers.

*** a minor degree of pain, magnified by fear, becomes unbearable Prenatal courses & training reduce fear, overcome ignorance, & build a womans self confidence.
Explain fetal development & childbirth Exercises to strengthen & relax muscles Breathing techniques Woman is not told that labor & delivery will be painless, analgesia & anesthesia will be available if needed Support given by husband, nurse & health care provider

The contrast of intrauterine environment and the external world causes infant to suffer psychological shock at the time of delivery Gentle controlled delivery Covers: Relaxing the craniosacral axis by supporting the head, neck and sacrum Restoring body heat loss by warm bath Allowing infant to breathe spontaneously Delaving cutting of cord to permit placental blood flow Bonding mother and infant by skin to skin contact

Leboyer method

Birthing room is darkened Soft music Infant placed immediately into a warmwater bath

Hydrotherapy and water birth

1. It strengthens the thigh and stretches the perineal muscles 2. Done at least 15 min/day Sit on floor with thighs apart, knees bent, legs parallel to each other, one ankle should NOT be on top of the other, push knees gently towards the floor until you feel the perineum stretch. Use this when watching TV, reading or entertaining friends. Do this for 15 minutes daily.
33 0

MLNG CELESTE, RN, MD

1. Helps to stretch muscle of the pelvic floor. 2. Done at least 15min/day When lifting something from the floor, bend knees rather than the back; do not squat on tiptoes but keep feet flat on the floor; incorporate this into daily activities; practice for 15 minutes daily
MLNG CELESTE, RN, MD 33 1

It is designed to strengthen pubococcygeus muscle. It may lead to increased sexual enjoyment. Each is a separate exercise and should be done 3x a day. 1. Squeeze the muscle surrounding the vagina as if stopping the flow of urine, hold for 3 seconds then relax. (10x) 2. Contract and relax the muscles surrounding the vagina as rapidly as possible 10 25x 3. Imagine that you are sitting in the bath tub of water and squeeze muscles as if sucking water into the vagina. Hold for 3 seconds then relax. 10x

1. strengthen the abdominal muscles 2. help prevent constipation 3. may be done as often as she wishes
Tighten

abdominal muscles, then relax and repeat as often as you can; can be done on lying or standing position along with pelvic floor contractions.

MLNG CELESTE, RN, MD

33 3

1. Helps to relieve backache during pregnancy and early labor 2. Makes the lumbar spine more flexible 3. Can be done on a variety of positions The woman arches her back, trying to lengthen or stretch her spine. She holds the position for 1 minute, and then hollows her back. - do this at the end of the day (5x)

MLNG CELESTE, RN, MD

33 4

1. SIT-UPS - Modified Purpose: Strengthen abdominal muscles. Good muscle tone is important for maintaining good posture, for effective pushing, and for early return of figure postpartum. Position: Backlying, knees bent, low back flat (pelvic tilt).

Exercise: Lift head and shoulders off floor, reaching hands toward knees (lift trunk to about 45 angle). Slowly return to starting position; do not drop back.

MLNG CELESTE, RN, MD

33 5

2. OBLIQUE (DIAGONAL) SIT-UPS - Modified Purpose: Strengthen oblique abdominal muscles. Position: Backlying, knees bent, low back flat. Exercise: As above, but reach up and across to the outside of the

MLNG CELESTE, RN, MD

33 6

1. Jogging: Wear good shoes; supportive bra. Keep pelvic floor muscles strong with Kegel exercises. Jog at a slower pace, shorter distances, less frequently. Remember: increased weight and laxity of ligaments means more strain on lower body (lower spine, hip joints, knees, ankles and feet). Do not overexert yourself. 2. Bicycling and Swimming: Excellent activities with reasonable limitations. Dont push yourself! 3. Tennis, Basketball, other sudden stop and start Activities. More awkward as bulk increases; listen to your body and slow down when necessary.
MLNG CELESTE, RN, MD

33 7

4. Skating, Horseback Riding: Danger of falling! Advise against. Consult your obstetrician or nurse practitioner as needed.

5. Walking: Most highly recommended for the pregnant woman; ideal alternative to more strenuous exercise. Walk uphill, downhill, and at different speeds. Patient Teaching: Consult your obstetrician or nurse practitioner early in your pregnancy. In general, you can continue your pre-pregnant routine of exercising. Stop when something hurts, or when you become fatigued. Know your limits, and avoid exercising to the point of exhaustion. It is generally advised that you not begin any new sport or activity during pregnancy. You may want to taper off your sports participation during the last few months, but you may still continue to exercise gently. Avoid exercising in very hot or humid weather, or at high altitudes if youre not used to it.
MLNG CELESTE, RN, MD 33 8

PRELIMINARY/ PRODROMAL SIGNS OF LABOR A. LIGHTENING ( the baby dropped) = THE SETTLING OF THE FETAL PRESENTING PART INTO THE PELVIC BRIM. IN PRIMIS, IT OCCURS 2 WEEKS BEFORE EDC ( 10-14 DAYS). IN MULTIS, ON OR BEFORE LABOR ONSET.

RESULTS OF LIGHTENING:
1.INCREASE IN URINARY FREQUENCY 2. RELIEF OF ABDOMINAL TIGHTNESS & DIAPRAGMATIC PRESSURE 3. SHOOTING PAINS DOWN THE LEGS DUE TO PRESSURE ON THE SCIATIC NERVE. 4. INCREASE IN THE AMOUNT OF VAGINAL DISCHARGES

6. LOSS OF WEIGHT OF ABOUT 2-3 LBS ONE TO TWO DAYS BEFORE LABOR ONSET = DECREASE IN PROGESTERONE THUS DECREASE IN FLUID RETENTION

B. Increase in the level of activity = due to increase in epinephrine release that is initiated by a decrease in progesterone produced by the placenta. Additional epinephrine prepares a womans body for the work of labor ahead. C. Braxton Hicks Contactions
D. Ripening of the cervix = internal sign seen only on pelvic exam. At term the cervix becomes butter soft

DIFFERENCES BETWEEN TRUE LABOR & FALSE LABOR:

FALSE LABOR 1.CONTRACTIONS REMAIN IRREGULAR TRUE LABOR 1. MAY BE SLIGHTLY IRREGULAR AT FIRST BUT BECOME REGULAR IN A MATTER OF HRS.

2. GENERALLY
CONFINED TO THE ABDOMEN

2. FIRST FELT IN THE

LOWER BACK & SWEEP AROUND TO THE ABDOMEN IN A GIRDLE LIKE FASHION.

3. NO INCREASE IN 3. INCREASE IN DURATION, INTENSITY

INTENSITY
& FREQUENCY

DURATION
& FREQUENCY

4. OFTEN
DISAPPEARS IF THE WOMAN AMBULATES

4. CONTINUE NO
MATTER WHAT THE WOMANS LEVEL OF ACTIVITY WALKING INTENSIFIES CONTRACTIONS.

5. ABSENT
CERVICAL CHANGES.

5. ACCOMPANIED BY
CERVICAL EFFACEMENT & DILATATION ( MOST IMPORTANT DIFFERENCE)

6. NO BLOOD
SHOW

6. BLOOD SHOW &

PROGRESSIVE FETAL DESCENT

THEORIES OF LABOR ONSET:

1. OXYTOCIN STIMULATION THEORY AS PREGNANCY NEARS TERM, OXYTOCIN PRODUCTION BY THE PPG INCREASE & AS A RESULT , THE UTERUS BECOME INCREASINGLY SENSITIVE TO OXYTOCIN. OXYTOCIN STIMULATES UTERINE CONTRACTIONS.

2. UTERINE STRETCH THEORY = ANY HOLLOW MUSCULAR ORGAN WHEN STRETCHED TO CAPACITY WILL CONTRACT & EMPTY. 3. PROGESTERONE DEPRIVATION THEORY - PROGESTERONE MAINTAINS PREGNANCY BY ITS RELAXANT EFFECT ON THE SMOOTH MUSCLES OF THE UTERUS.AS PREGNANCY NEARS TERM, PROGESTERONE PRODUCTION

DECREASE. WHEN PROGESTERONE LEVEL DROPS, UTERINE CONTRACTION OCCURS. 4. THEORY OF THE AGING PLACENTA
- AS THE PLACENTA AGES, IT BECOMES LESS EFFICIENT & AS A RESULT , IT PRODUCES LESS & LESS AMOUNT OF PROGESTERONE & ALLOWS CONCENTRATION OF PROSTAGLANDIN & ESTROGEN TO RISE STEADILY WHICH RESULTS TO RHYTHMIC REGULAR

& STRONG UTERINE CONTRACTIONS.

SIGNS OF TRUE LABOR:

1. UTERINE CONTRACTIONS THE SUREST SIGN THAT LABOR HAS BEGUN IS THE INITIATION OF EFFECTIVE PRODUCTIVE UTERINE CONTRACTIONS.

2. IF RUPTURE OF MEMBRANES ( ROM) IS SUSPECTED, CONFIRMATION CAN BE DONE BY TESTING THE VAGINAL DISCHARGE WITH A NITRAZINE PAPER. ** PAPER TURNS BLUE SINCE AMNIOTIC FLUID IS ALKALINE. ** PAPER TURNS YELLOW IF FLUID IS URINE SINCE URINE IS ACIDIC.

ONCE MEMBRANES ( BOW) HAVE RUPTURED:

1.LABOR IS INEVITABLE. IT WILL OCCUR WITHIN 24 HOURS. 2. THE INTEGRITY OF THE UTERUS HAS BEEN DESTROYED . INFECTION, THEREFORE CAN EASILY SET IN. 3.ASEPTIC TECHNIQUES SHOULD BE OBSERVED IN ALL PROCEDURES. DOCTORS DO LESS MANIPULATIONS ( EX. IE)

4. ENEMA IS NO LONGER REQUIRED.

5. UMBILICAL CORD COMPRESSION & OR CORD PROLAPSE CAN OCCUR ESPECIALLY IN BREECH PRESENTATIONS ** A WOMAN IN LABOR SEEKING ADMISSION TO THE HOSPITAL & SAYING THAT HER BOW HAS RUPTURED SHOULD BE PUT TO BED IMMEDIATELY & THE FETAL HEART TONES TAKEN CONSEQUENTLY.

** IF A WOMAN IN LABOR SAYS SHE FEELS A LOOP OF THE CORD IS COMING OUT OF THE VAGINA ( CORD PROLAPSE), THE FIRST NURSING ACTION IS TO PUT HER IN KNEE CHEST POSITION OR TRENDELENBURG POSITION ( IN ORDER TO REDUCE PRESSURE ON THE CORD. REMEMBER: ONLY 5 MINUTES OF CORD COMPRESSION CAN ALREADY LEAD TO IRREVERSIBLE BRAIN DAMAGE OR EVEN FETAL DEATH.

IN ADDITION, APPLY A WARM SALINE SATURATED OS ON THE PROLAPSED CORD TO PREVENT DRYING OF THE CORD.
3. SHOW THIS IS DUE TO PRESSURE OF THE DESCENDING PRESENTING PART OF THE FETUS WHICH CAUSES RUPTURE OF MINUTE CAPILLARIES IN THE MUCUS MEMBRANE OF THE CERVIX.BLOOD MIXES WITH MUCUS WHEN OPERCULUM ( MUCUS PLUG) IS RELEASED.

.
2. SHOW IS THE COMMON TERM USED TO DESCRIBE THE RELEASE OF THE CERVICAL PLUG OR MUCUS PLUG CALLED OPERCULUM THAT FORMED DURING PREGNANCY. BLOOD released from these ruptured capillaries mixes with OPERCULUM ( MUCUS PLUG) giving it a pinkish coloration. When the cervix dilates, this blood tinged mucus, called SHOW is released.

LABOR AND DELIVERY

LABOR = PHYSICAL & MECHANICAL PROCESS IN WHICH THE BABY, THE PLACENTA & FETAL MEMBRANES ARE PROPELLED THROUGH THE PELVIS & ARE EXPELLED FROM THE BIRTH CANAL.
DELIVERY = ACTUAL EVENT OF BIRTH

PS IN LABOR & DELIVERY

1. PASSENGER = THE FETUS 2. PASSAGEWAY = THE BIRTH CANAL 3. POWERS OF LABOR= FORCE OF UTERINE CONTRACTIONS

4. PLACENTAL IMPLANTATION 5. PSYCHE of the mother is preserved so that afterward, labor can be viewed as a positive experience 1. THE PASSENGER ( FETUS) = THE FETAL SKULL = FROM AN OBSTETRICAL
POINT OF VIEW, THE FETAL SKULL IS THE MOST IMPORTANT PART OF THE FETUS BECAUSE:
A. IT IS THE LARGEST PART OF THE BODY

B. IT IS THE MOST FREQUENT PRESENTING PART

C. IT IS THE LEAST COMPRESSIBLE OF ALL PARTS

A. CRANIAL BONES
1. FRONTAL 2. PARIETAL 3. OCCIPITAL

B. MEMBRANE SPACES = SUTURE LINES ARE IMPORTANT BECAUSE THEY ALLOW THE BONES TO MOVE AND OVERLAP, CHANGING THE SHAPE OF THE FETAL HEAD IN ORDER TO FIT THROUGH THE BIRTH CANAL, A PROCESS CALLED MOLDING. 1. SAGITTAL SUTURE LINE = THE MEMBRANOUS INTERSPACE WHICH JOINS THE 2 PARIETAL BONES. 2. CORONAL SUTURE LINE = THE MEMBRANOUS INTERSPACE WHICH JOINS THE FRONTAL BONE AND THE PARIETAL BONES.

3. LAMBDOIDAL SUTURE LINE C. FONTANELLES = MEMBRANE COVERED SPACES AT THE JUNCTION OF THE MAIN SUTURE LINES: 1. ANTERIOR FONTANELLE = THE LARGER, DIAMOND SHAPED FONTANEL WHICH CLOSES BETWEEN 12 TO 18 MONTHS IN AN INFANT

2. POSTERIOR FONTANELLE = THE SMALLER TRIANGULAR SHAPED FONTANEL WHICH CLOSES BETWEEN 2-3 MONTHS IN THE INFANT. THE SPACE BETWEEN THE TWO FONTANELLES IS REFERRED TO AS THE VERTEX. D. MEASUREMENTS THE SHAPE OF THE FETAL SKULL CAUSES IT TO BE WIDER IN ITS ANTEROPOSTERIOR (AP) DIAMETER THAN IN ITS TRANSVERSE DIAMETER.

1. TRANSVERSE DIAMETER OF THE FETAL SKULL: I. BIPARIETAL = 9.25CM TO 9.5 II. BITEMPORAL = 8 CM. III. BIMASTOID = 7 CM. 2. ANTEROPOSTERIOR DIAMETERS I. SUBOCCIPITOBREGMATIC = FROM BELOW THE OCCIPUT TO THE CENTER OF THE ANTERIOR FONTANELLE = 9.5 CM ( THE NARROWEST AP DIAMETER)

II. OCCIPITOFRONTAL = FROM THE OCCIPITAL PROMINENCE TO THE BRIDGE OF THE NOSE = 12 CM. III. OCCIPITOMENTAL = FROM THE POSTERIOR FONTANELLE TO THE CHIN = 13.5 CM (THE WIDEST AP DIAMETER)

FETAL PRESENTATION AND POSITION:

ATTITUDE: describes the degree of flexion or extension a fetus assumes during labor or the relation of the fetal parts to each other a. VERTEX OR OCCIPUT ( MOST COMMON) = THE HEAD IS FULLY FLEXED ON THE CHEST MAKING THE PARIETAL BONES OR THE SPACE BETWEEN THE FONTANELLES, THE

 VERTEX THE PRESENTING PART, (ALLOWS THE SUBOCCIPITOBREGMATIC DIAMETER TO PRESENT TO THE CERVIX).

b. SINCIPUT = ( MILITARY POSITION) = HEAD IS MODERATELY FLEXED, THE SINCIPUT BECOMES THE PRESENTING PART.

4. FACE = THE HEAD IS EXTENDED & THE FACE IS THE PRESENTING PART.( FROM THIS POSITION, EXTREME EDEMA & DISTORTION OF THE FACE MAY OCCUR.

4. MENTUM ( CHIN) = HEAD IS HYPEREXTENDED TO PRESENT THE CHIN. THE WIDEST DIAMETER ( OCCIPITOMENTAL IS PRESENTING). AS A RULE, THE FETUS CANNOT ENTER THE PELVIS IN THIS PRESENTATION.THE PRESENTING DIAMETER, THE OCCIPITOMENTAL IS SO WIDE BIRTH MAY BE IMPOSSIBLE

** WHICH ONE OF THESE DIAMETERS IS PRESENTED AT THE BIRTH CANAL DEPENDS ON THE DEGREE OF FLEXION (ATTITUDE) THE FETAL HEAD ASSUMES PRIOR TO DELIVERY. IN FULL FLEXION, ( VERY GOOD ATTITUDE WHEN THE CHIN IS FLEXED ON THE CHEST), THE SMALLEST SUBOCCIPITOBREGMATIC DIAMETER IS THE ONE PRESENTED AT THE BIRTH CANAL. IF IN POOR FLEXION, THE WIDEST OCCIPITOMENTAL DIAMETER WILL BE THE ONE

PRESENTED & WILL GIVE MOTHER & BABY MORE PROBLEMS.

ENGAGEMENT = REFERS TO THE SETTLING OF THE PRESENTING PART OF THE FETUS FAR ENOUGH INTO THE PELVIS TO BE AT THE LEVEL OF THE ISCHIAL SPINES , A MIDPOINT OF THE PELVIS. DESCENT TO THIS POINT MEANS THAT THE WIDEST PART OF THE FETUS (THE BIPARIETAL DIAMETER IN A CEPHALIC PRESENTATION, THE INTERTROCHANTERIC DIAMETER IN A

BREECH PRESENTATION) HAS PASSED THROUGH THE PELVIS OR THE PELVIC INLET HAS BEEN PROVEN ADEQUATE FOR BIRTH. IN A PRIMIPARA, NONENGAGEMENT OF THE HEAD AT THE BEGINNING OF LABOR INDICATES A POSSIBLE COMPLICATION SUCH AS ABNORMAL PRESENTATION OR POSITION, ABNORMALITY OF THE FETAL HEAD, OR CEPHALOPELVIC DISPROPORTION (CPD).

IN PRIMIPARAS, ENGAGEMENT MAY OR MAY NOT BE PRESENT AT THE BEGINNING OF LABOR. A PRESENTING PART THAT IS NOT ENGAGED IS SAID TO BE FLOATING. ONE THAT IS DESCENDING BUT HAS NOT YET REACHED THE ISCHIAL SPINES CAN BE SAID TO BE DIPPING. THE DEGREE OF ENGAGEMENT IS ASSESSED BY VAGINAL & CERVICAL EXAMINATION.

FETAL STATION: The

relationship of the presenting part to an imaginary line drawn between the ischial spine (the narrowest diameter through which the fetus must pass to be born vaginally) and the maternal pelvis.

**STATION 0 = PRESENTING PART IS AT THE LEVEL OF THE ISCHIAL SPINES (SYNONYMOUS WITH ENGAGEMENT) ** STATION -1 = PRESENTING PART IS 1CM ABOVE THE ISCHIAL SPINES ** STATION +1 = PESENTING PART IS 1CM BELOW THE ISCHIAL SPINES

** STATION +3 OR +4 = THE PRESENTING PART IS AT THE PERINEUM & CAN BE SEEN IF THE VULVA IS SEPARATED; SYNONYMOUS TO CROWNING. ( ENCIRCLING OF THE LARGEST DIAMETER OF THE FETAL HEAD BY THE VULVAR RING).

FETAL LIE = IS THE RELATIONSHIP BETWEEN THE LONG AXIS OF THE MOTHER TO THE LONG AXIS OF THE FETAL BODY. 2 KINDS OF LIE 1. LONGITUDINAL LIE = LONG AXIS OF THE FETUS IS PARALLEL TO THE LONG AXIS OF THE MOTHER. 2. TRANSVERSE LIE = LONG AXIS OF THE FETUS IS PERPENDICULAR ( RIGHT ANGLE)TO THE LONG AXIS OF THE MOTHER.

CAUSES OF TRANSVERSE LIE:

1.MULTIPARITY
2. CONTRACTED PELVIS

3. PLACENTA PREVIA

A.LONGITUDINAL OR VERTICAL LIE: 1. CEPHALIC PRESENTATION (95%)= MEANS THAT THE HEAD IS THE BODY PART THAT FIRST CONTACTS THE CERVIX. a. VERTEX OR OCCIPUT B. BROW C. FACE D. MENTUM

2. Pelvic or Breech Presentation:

3% = MEANS THAT EITHER THE BUTTOCKS OR FEET ARE THE FIRST BODY PARTS TO CONTACT THE CERVIX.

a. COMPLETE BREECH =

= FETUS HAS THIGHS TIGHTLY FLEXED ON THE ABDOMEN; BOTH THE BUTTOCKS & THE TIGHTLY FLEXED FEET PRESENT TO THE CERVIX.
b. FRANK BREECH =

= HIPS ARE FLEXED BUT THE KNEES ARE EXTENDED TO REST ON THE CHEST. THE BUTTOCKS ALONE PRESENT TO THE CERVIX.

Complete breech

Frank breech

Single footling

c. FOOTLING
= FOOT PRESENT AT THE INTROITUS. NEITHER THE THIGHS NOR LOWER LEGS ARE FLEXED. ** SINGLE FOOTLING ONE LEG IS EXTENDED AT THE HIP & KNEE & THE OTHER LEG PRESENTS IN THE INTROITUS.

** DOUBLE FOOTLING BOTH LEGS ARE UNFLEXED & BOTH FEET ARE THE PRESENTING PART.

3. TRANSVERSE LIE/ HORIZONTAL LIE = PRESENTING PART IS ONE OF THE SHOULDERS ( ACROMIUM PROCESS), A HAND, AN ELBOW, OR AN ILIAC CREST.

POSSIBLE INJURIES IN BREECH PRESENTATION: 1.CORD PROLAPSE/CORD COMPRESSION

2. INTRACRANIAL HEMORRHAGE CAUSED BY UNMOLDING

3. ERBS PARALYSIS 4. HIP DISLOCATION 5. FRACTURE OF THE CLAVICLE 6. PREMATURE SEPARATION OF THE PLACENTA

POSITION = REFERS TO THE RELATIONSHIP OF THE PRESENTING PART TO A SPECIFIC QUADRANT OF THE WOMANS PELVIS.

QUADRANTS OF THE MATERNAL PELVIS: A. RIGHT ANTERIOR B. LEFT ANTERIOR C. RIGHT POSTERIOR D. LEFT POSTERIOR E. TRANSVERSE

4 PARTS OF THE FETUS CHOSEN AS LANDMARKS:

1.OCCIPUT O- VERTEX PRESENTATION

2. MENTUM M(CHIN) FACE PRESENTATION 3. SACRUM Sa IN BREECH PRESENTATION

4. SCAPULA Sc IN SHOULDER PRESENTATION

POSITION IS IMPORTANT BECAUSE IT INFLUENCES THE PROCESS & EFFICIENCY OF LABOR. TYPICALLY, A FETUS DELIVERS FASTEST FROM AN LOA LEFT OCCIPITO ANTERIOR ( MOST COMMON) & ROA RIGHT OCCIPITO ANTERIOR ( 2ND MOST COMMON). POSTERIOR POSITIONS MAY BE MORE PAINFUL FOR THE MOTHER BECAUSE THE ROTATION OF THE FETAL HEAD PUTS PRESSURE ON THE SACRAL NERVES, CAUSING SHARP BACK PAINS.( BACK LABOR)

II THE PASSAGEWAY (THE BIRTH CANAL)

A.THE PELVIS

Narrow oval shape, resembles Ape pelvis

Wide but flat; May still allow vaginal delivery

a. Gynecoid classic female pelvis inlet, well rounded (oval); ideal for delivery - most ideal for childbirth (50% of women) b. Android resembling a male pelvis, narrow and heart-shaped; usually requires cesarean section or difficult forceps delivery (20% of women) c. Platypelloid flat, broad pelvis;rarest type of pelvis; usually not adequate but may still allow vaginal delivery (5% of women) d. Anthropoid similar to pelvis of anthropoid ape; long & deep. Narrow transverse & wide AP does not conform to the head of the baby;(25% of women)
414

DIVISIONS OF THE PELVIS:

1.FALSE PELVIS = SUPERIOR HALF; SUPPORTS THE UTERUS DURING THE LATE MONTHS OF PREGNANCY & AIDS IN DIRECTING THE FETUS INTO THE TRUE PELVIS FOR BIRTH. 2.TRUE PELVIS = : INFERIOR HALF; FORMED BY THE PUBES IN FRONT, THE ILIA & THE ISCHIA ON THE SIDES & THE SACRUM & COCCYX BEHIND.

** THE FALSE PELVIS IS DIVIDED FROM THE TRUE PELVIS ONLY BY AN IMAGINARY LINE: THE LINEA TERMINALIS DRAWN FROM THE SACRAL PROMINENCE AT THE BACK TO THE SUPERIOR ASPECT OF THE SYMPHYSIS PUBIS AT THE FRONT OF THE PELVIS. **

** Internal pelvic measurements give the actual diameters of the inlet and outlet through which the fetus must pass.

The True Pelvis consists of the following parts:

1.Pelvic Inlet or Pelvic brim entrance to the true

pelvis a. DIAGONAL CONJUGATE = DISTANCE BETWEEN THE ANTERIOR SURFACE OF THE SACRAL PROMINENCE AND THE ANTERIOR SURFACE OF THE INFERIOR MARGIN OF THE SYMPHYSIS PUBIS. ( MEASURED BY INTERNAL EXAMINATION) ADEQUATE = 12.5 TO 13 CMS ** THE MOST USEFUL MEASUREMENT FOR ESTIMATION OF THE PELVIC SIZE, IT SUGGESTS THE AP OF THE PELVIC INLET ( THE NARROWEST DIAMETER AT THAT LEVEL) ** THE DIAMETER OF THE FETAL HEAD THAT MUST PASS THAT POINT AVERAGES 9 CM DIAMETER

** DC suggests the AP diameter of the pelvic inlet ( the narrowest diameter at that level, or the one that is most apt to cause a misfit with the fetal head) - To measure, 2 fingers are introduced vaginally and pressed inward and upward until the middle finger touches the sacral prominence.

B. TRUE CONJUGATE/ CONJUGATA VERA = THE DISTANCE BETWEEN THE ANTERIOR SURFACE OF THE SACRAL PROMINENCE AND THE POSTERIOR SURFACE OF THE INFERIOR MARGIN OF THE SYMPHYSIS PUBIS.
= Average 10.5 TO 11 cm

= MEASUREMENT CANNOT BE MADE DIRECTLY BUT IS ASCERTAINED BY SUBTRACTING 1.5 TO 2 CM FROM THE DIAGONAL CONJUGATE.( SYMPHYSIS PUBIS DIAMETER IS ASSUMED TO BE 1.5 TO 2 CM IN DEPTH)
= ACTUAL

DIAMETER OF THE PELVIC INLET THROUGH WHICH THE FETAL HEAD MUST PASS

c. OBSTETRIC CONJUGATE =
= THE DISTANCE BETWEEN THE MIDPOINT OF THE SACRAL PROMONTORY TO THE UPPER MARGIN OF THE SYMPHYSIS PUBIS. = CAN ONLY BE MEASURED RADIOGRAPHICALLY

2. MIDPELVIS/ PELVIC CAVITY/ PELVIC CANAL = THE SPACE BETWEEN THE INLET &
THE OUTLET. THIS IS NOT A STRAIGHT LINE BUT A CURVED PASSAGE.THE CURVATURE IS SO DESIGNED BY NATURE TO CONTROL THE SPEED OF DESCENT OF THE FETAL HEAD. RAPID FETAL DESCENT CAN RESULT TO RUPTURE OF CEREBRAL ARTERIES DUE TO THE SUDDEN CHANGE OF PRESSURE. Interspinous ( smallest diameter of the pelvis ) 10 cm AP diameter at level of ischial spines = 11.5 cm

3. PELVIC OUTLET = THE INFERIOR PORTION OF THE PELVIS. THE MOST IMPORTANT DIAMETER OF THE OUTLET IS ITS TRANSVERSE OR BI-ISCHIAL DIAMETER( DISTANCE BETWEEN THE TWO ISCHIAL TUBEROSITIES) WHICH IS ABOUT 11.5 CM

ISCHIAL TUBEROSITY DIAMETER

Distance between the ischial tuberosities or the

transverse diameter of the OUTLET( the narrowest diameter at that level) or the one most apt to cause misfit. A pelvimeter is generally used but a ruler can be used or clenched fist measurement. Adequate: 11 cm ( because it will allow the widest diameter of the fetal head or 9 cm to pass freely.

** CONTRACTED PELVIS A PELVIS WITH A MEASUREMENT OF LESS THAN 1.5 TO 2 CM IN ANY OF ITS IMPORTANT DIAMETERS THUS MAKING VAGINAL DELIVERY OF THE FETUS NOT POSSIBLE
**PELVIC MEASUREMENTS ( XRAY PELVIMETRY) ARE PREFERABLY DONE AFTER THE 6TH LUNAR MONTH. IT IS THE MOST EFFECTIVE METHOD OF DIAGNOSING CEPHALOPELVIC DISPROPORTION (CPD). BUT SINCE X-RAYS ARE TERATOGENIC, THE PROCEDURE CAN ONLY BE DONE 2 WEEKS BEFORE DELIVERY.

III POWERS a. INVOLUNTARY UTERINE CONTRACTIONS

b. VOLUNTARY PUSHING EFFORTS OF THE MOTHER

PHASES OF UTERINE CONTRACTIONS: 1.INCREMENT = WHEN THE INTENSITY OF THE CONTRACTIONS INCREASES 2. ACME = WHEN THE CONTRACTIONS ARE AT ITS STRONGEST

3. DECREMENT = WHEN THE INTENSITY DECREASES

CHARACTERISTICS OF UTERINE CONTRACTIONS:

1. DURATION = REFERS TO THE LENGTH OF CONTRACTIONS STARTING FROM THE BEGINNING OF ONE CONTRACTION TO THE END OF SAME CONTRACTION.

2. FREQUENCY = STARTS FROM THE BEGINNING OF ONE CONTRACTION TO THE BEGINNING OF THE NEXT CONTRACTION. 3. INTERVAL = REFERS TO THE REGULARITY OF CONTRACTIONS. IT STARTS FROM THE END OF ONE CONTRACTION TO THE BEGINNING OF THE NEXT CONTRACTION.

4. INTENSITY = REFERS TO THE STRENGTH OF UTERINE CONTRACTIONS. a. MILD IF THE FUNDUS IS SLIGHTLY TENSE & EASY TO INDENT WITH FINGERTIPS
b. MODERATE IF THE FUNDUS IS FIRM & IS DIFFICULT TO INDENT WITH FINGERTIPS

c. STRONG IF THE FUNDUS IS HARD & RIGID & ALMOST IMPOSSIBLE TO INDENT. ** AS LABOR CONTRACTIONS PROGRESS & BECOME REGULAR & STRONG, THE UTERUS GRADUALLY DIFFERENTIATES ITSELF INTO TWO DISTINCT FUNCTIONING AREAS. THE UPPER PORTION BECOMES THICKER & ACTIVE, PREPARING TO EXERT ITS STRENGTH NECESSARY TO EXPEL THE

FETUS. THE LOWER PORTION BECOME THIN WALLED, SUPPLE & PASSIVE, SO THE FETUS CAN BE EXPELLED OUT EASILY.THE BOUNDARY BETWEEN THE TWO PORTIONS BECOMES MARKED BY A RIDGE CALLED PHYSIOLOGIC RETRACTION RING
IN A DIFFICULT LABOR ( DYSTOCIA), THE RING MAY BECOME PROMINENT & OBSERVABLE AS AN ABDOMINAL INDENTATION. THIS IS

TERMED AS PATHOLOGIC RETRACTION RING OR BANDLS RING A DANGER SIGN THAT SIGNIFIES IMPENDING RUPTURE OF THE LOWER UTERINE SEGMENT.

CERVICAL CHANGES:
- EVEN MORE MARKED THAN THE CHANGES IN THE BODY OF THE UTERUS ARE TWO CHANGES THAT OCCUR IN THE CERVIX: 1.EFFACEMENT = SHORTENING & THINNING OF THE CERVICAL CANAL. NORMALLY THE CANAL IS 1-2 CM LONG. WITH EFFACEMENT, THIS CANAL VIRTUALLY DISAPPEARS.THIS IS EXPRESSED IN PERCENTAGE ( % )

2. DILATATION REFERS TO THE ENLARGEMENT OF THE CERVICAL CANAL FROM AN OPENING A FEW MMLLIMETERS WIDE TO ONE LARGE ENOUGH ( APPROXIMATELY 10 CM) TO PERMIT PASSAGE OF THE FETUS.

IV PLACENTAL IMPLANTATION
a. IF THE PLACENTA HAS IMPLANTED NORMALLY IN THE FUNDAL PORTION OF THE UTERUS ( ANTERIOR OR POSTERIOR), IT RARELY CAUSE TROUBLE DURING LABOR & DELIVERY. b. WHEN MALIMPLANTATION OF THE PLACENTA OCCURS IN THE LOWER UTERINE SEGMENT, IT NECESSITATES MEDICAL OR SURGICAL INTERVENTION.

Stage 1 = Stage of Cervical Dilatation Stage 2 = Stage of Fetal Expulsion

Stage 3 = Stage of Placental Expulsion

Stage 4 = Stage of Puerperium or Vigilance

LENGTH OF LABOR: STAGE PRIMIS MULTIS

1ST STAGE
2ND STAGE

10-12 HRS
2 HRS

6-8 HRS
20 TO 90 MIN

AVE. 50 MIN
3RD STAGE 5 TO 20 MIN

AVE. 20 MIN
5 TO 20 MIN

4TH STAGE

2 TO 4 HRS

2 TO 4 HRS

STAGES OF LABOR
A.FIRST STAGE OF LABOR ( STAGE OF CERVICAL DILATATION) FROM THE ONSET OF TRUE LABOR PAINS & ENDS WITH COMPLETE DILATATION OF THE CERVIX. (10 CM).

Care of the Parturient

PHASES OF THE FIRST STAGE OF LABOR: 1. LATENT PHASE:

DILATATION: 0-3 CMS

INTENSITY: MILD & SHORT CONTRACTIONS

DURATION:20-30 SECONDS
INTERVAL: 15 20 MINS MULTIS : 4-5 HRS NULLI 6 HRS

BREATHING: SLOW, DEEP CHEST BREATHING OR ABDOMINAL BREATHING Z9 12-15 BPM)

ELECTRONIC FETAL MONITORING:

1.EXTERNAL OR INDIRECT MONITORING a. APPLIED WHEN MEMBRANES ARE STILL INTACT SUCH AS TOCODYNAMOMETER AND UTERINE TRANSDUCER. 2. INTERNAL OR DIRECT MONITORING A. APPLIED WHEN MEMBRANES HAVE RUPTURED & CERVIX HAS DILATED 2-3 CM.

** MOTHER IS EXCITED WITH SOME DEGREE OF APPREHENSION BUT STILL WITH ABILITY TO COMMUNICATE. ** TAKES UP 8 OF THE 12 HOUR FIRST STAGE. ** BEST TIME TO TEACH BREATHING TECHNIQUES BECAUSE THE WOMAN IS STILL COMFORTABLE, COOPERATIVE & CAN STILL CONCENTRATE ON A CONVERSATION WELL.

2. ACTIVE PHASE
DILATATION: 4 7 CMS. INTENSITY: MODERATE DURATION: 30 50 SECONDS INTERVAL: 3 -5 MINUTES ** THIS PHASE LASTS APPROXIMATELY 3 HOURS IN A NULLIPARA & 2 HOURS IN A MULTIPARA. ** ANESTHESIA IS GIVEN DURING THIS PHASE AT 5-6 CM DILATATION.

TYPES OF ANESTHESIA
a. PARACERVICAL TRANSVAGINAL INJECTION INTO EITHER SIDE OF THE CERVIX. PATIENT ON LITHOTOMY POSITION. COUPLED WITH A LOCAL ANESTHETIC, RESULTS IN A PAINLESS CHILDBIRTH ( UTERINE CONTRACTIONS ARE NOT FELT BY THE MOTHER) b. PUDENDAL INJECTION THROUGH THE SACROSPINOUS LIGAMENT INTO

POSTERIOR AREOLAR TISSUES TO REDUCE PERCEPTION OF PAIN DURING SECOND STAGE & MAKE MOTHER COMFORTABLE. PATIENT IS ON LITHOTOMY POSITION.
SIDE EFFECT: ECCHYMOSIS = PURPLISH DISCOLORATION OF THE SKIN DUE TO BLOOD IN THE SUBCUTANEOUS TISSUES

NURSING CARE: APPLY ICE BAG TO THE AREA ON THE FIRST DAY WHICH COULD REDUCE SWELLING.

C. EPIDURAL INJECTION OF LOCAL ANESTHETIC AT THE LUMBAR LEVEL OUTSIDE THE DURA MATER ** POST SPINAL HEADACHES MAY BE DUE TO LEAKAGE OF ANESTHETICS INTO THE CSF OR INJECTION OF AIR AT TIME OF NEEDLE INSERTION.
NURSING MX: ** FLAT ON BED FOR 12 HOURS & INCREASE FLUID INTAKE.

NURSING MX: - TURN TO SIDE - PROMPT ELEVATION OF LEGS - ADMINISTRATION OF VASOPRESSOR & O2 AS ORDERED

*** A SURE SIGN THAT THE BABY IS ABOUT TO BE BORN IS THE BULGING OF THE PERINEUM. IN GENERAL, PRIMIGRAVIDAS ARE TRANSPORTED FROM LR TO DR WHEN THERE IS BULGING OF THE PERINEUM ( 10 CM); MULTIPARAS ARE TRANSPORTED AT 7-8 CM CERVICAL DILATATION OR AT +1+2***

3. TRANSITION PHASE ** WHEN THE MOOD OF THE WOMAN SUDDENLY CHANGES & THE NATURE OF THE CONTRACTIONS INTENSIFY **
DILATATION: 8 10 CM

INTENSITY: STRONG
DURATION: 60 90 SECONDS

INTERVAL: 2-3 MINUTES

STATION: +1 +2

*** A SURE SIGN THAT THE BABY IS ABOUT TO BE BORN IS THE BULGING OF THE PERINEUM. IN GENERAL, PRIMIGRAVIDAS ARE TRANSPORTED FROM LR TO DR WHEN THERE IS BULGING OF THE PERINEUM ( 10 CM); MULTIPARAS ARE TRANSPORTED AT 7-8 CM CERVICAL DILATATION OR AT +1+2***

CHARACTERISTICS:
1.IF THE MEMBRANES ARE STILL INTACT, THIS PERIOD IS MARKED BY A SUDDEN GUSH OF AMNIOTIC FLUID, AS FETUS IS PUSHED TO THE BIRTH CANAL. 2. IF SPONTANEOUS RUPTURE DOES NOT OCCUR, AMNIOTOMY ( SNIPPING OF BOW WITH A STERILE POINTED INSTRUMENT TO ALLOW AMNIOTIC FLUID TO DRAIN) IS DONE TO PREVENT FETUS FROM ASPIRATING

THE AMNIOTIC FLUID AS IT MAKES ITS DIFFERENT POSITION CHANGES. AMNIOTOMY HOWEVER CANNOT BE DONE IF STATION IS STILL AT MINUS AS THIS CAN LEAD TO CORD COMPRESSION.
3. THERE IS AN UNCONTROLLABLE URGE TO PUSH WITH CONTRACTIONS, A SIGN OF AN IMPENDING SECOND STAGE OF LABOR.

4. PERINEAL PREPARATION THE PUBIC HAIR ON THE LOWER HALF OF THE VULVA & THE PERINEUM IS REMOVED BY SHAVING TO MAKE IT CLEAN & TAUT.

REASONS FOR ADMINISTRATION OF ENEMA:

a. TO PREVENT INFECTION TO BOTH THE MOTHER & THE FETUS. b. IT HELPS TO INCREASE UTERINE CONTRACTIONS. c. PREVENTS POSTPARTUM DISCOMFORT d. TO FACILITATE THE DESCENT OF THE FETUS TO THE BIRTH CANAL.

CONTRAINDICATIONS OF ENEMA:
a. MALPRESENTATION & POSITION

b. VAGINAL BLEEDING
c. RUPTURED BAG OF WATERS

d. CROWNING
e. PLACENTA PREVIA

NOTE: CHECKING THE BLOOD PRESSURE SHOULD BE DONE MIDWAY BETWEEN CONTRACTIONS BECAUSE IT NORMALLY INCREASES DURING A CONTRACTION.
FHR SHOULD NOT BE TAKEN DURING UTERINE CONTRACTIONS SINCE IT TENDS TO SLOW DOWN AS INDUCED BY THE COMPRESSION OF THE FETAL HEAD DURING UTERINE CONTRACTIONS

NURSING ALERT:ANY CHANGE IN THE FHR, THE FIRST NURSING ACTION IS TO CHANGE THE POSITION OF THE MOTHER ( LLP)

B. SECOND STAGE OF LABOR ( STAGE OF EXPULSION) = BEGINS WITH COMPLETE DILATATION ( 10 CM) & ENDS WITH THE DELIVERY OF THE BABY. = MOST CRITICAL STAGE ON THE PART OF THE FETUS

CARDINAL MOVEMENTS/ MECHANISM OF LABOR / FETAL POSITION CHANGES: ENGAGEMENT = SYNONYMOUS TO STATION 0 1. DESCENT = DOWNWARD MOVEMENT OF THE BIPARIETAL DIAMETER OF THE FETAL HEAD TO WITHIN THE PELVIC INLET.( occurs due to the pressure on the fetus by the uterine fundus) THE PRESSURE OF THE FETUS ON THE SACRAL NERVES CAUSES THE MOTHER TO EXPERIENCE A PUSHING SENSATION.

2. FLEXION = AS FETAL HEAD REACHES PELVIC FLOOR, PRESSURE FROM THE PELVIC FLOOR CAUSES THE FETAL HEAD TO BEND FORWARD ONTO THE CHEST. THIS PERMITS THE SMALLEST AP DIAMETER (SUBOCCIPITOBREGMATIC DIAMETER) TO PRESENT IN THE OUTLET.

3. INTERNAL ROTATION THE HEAD FLEXES & THE OCCIPUT ROTATES UNTIL IT IS SUPERIOR, OR JUST BELOW THE SYMPHYSIS PUBIS BRINGING THE HEAD TO THE BEST RELATIONSHIP TO THE OUTLET OF THE PELVIS. ( SMALLEST DIAMETER IS PRESENTED TO THE PELVIC OUTLET).

4. EXTENSION = AS THE HEAD COMES OUT, THE BACK OF THE NECK STOPS AT THE PUBIC ARCH & ACTS AS A PIVOT FOR THE REST OF THE HEAD. THE HEAD EXTENDS & THE FOREHEAD, NOSE, MOUTH & FINALLY THE CHIN APPEAR.

REMEMBER:
-THE HEAD SHOULD BE DELIVERED IN BETWEEN CONTRACTIONS. ** INSERT TWO FINGERS INTO THE VAGINA SO AS TO FEEL FOR THE PRESENCE OF A CORD LOOPED AROUND THE NECK ( NUCHAL CORD ).

5. EXTERNAL ROTATION =( RESTITUTION)

- AS THE HEAD IS BORN IT ROTATES BRIEFLY BACK TO DIAGONAL OR TRANSVERSE POSITION OF THE EARLY PART OF LABOR, (THE POSITION IT OCCUPIED WHEN IT WAS ENGAGED) BRINGING THE SHOULDER TO AN AP POSITION.

** AS THE HEAD ROTATES, DELIVER THE ANTERIOR SHOULDER BY EXERTING A GENTLE DOWNWARD PUSH & THEN SLOWLY GIVE AN UPWARD LIFT TO DELIVER THE POSTERIOR SHOULDER

6. EXPULSION = WITH THE DELIVERY OF THE SHOULDERS, THE REST OF THE BABY IS BORN EASILY & SMOOTHLY BECAUSE OF ITS SMALLER SIZE & BIRTH IS COMPLETED.( END OF PELVIC DIVISION OF LABOR

NURSING CARE:
a.WHEN POSITIONING LEGS IN LITHOTOMY POSITION, PUT THEM UP AT THE SAME TIME TO PREVENT INJURY TO THE UTERINE LIGAMENTS. b. AS SOON AS THE FETAL HEAD CROWNS, INSTRUCT THE MOTHER NOT TO PUSH BUT TO PANT INSTEAD ( RAPID & SHALLOW BREATHING), TO PREVENT RAPID EXPULSION OF THE BABY.

c. IF PANTING IS DEEP & RAPID, CALLED HYPERVENTILATION,THE PATIENT WILL EXPERIENCE LIGHTHEADEDNESS & TINGLING SENSATION OF THE FINGERS LEADING TO CARPOPEDAL SPASMS BECAUSE OF RESPIRATORY ALKALOSIS. MX:
- LET THE PATIENT BREATHE INTO A PAPER BAG TO RECOVER LOST CARBON DIOXIDE.( A CUPPED HAND WILL SERVE THE SAME PURPOSE)

d. ASSIST IN EPISIOTOMY INCISION MADE IN THE PERINEUM PRIMARILY TO: 1. PREVENT LACERATIONS

2. PREVENT PROLONGED & SEVERE STRETCHING OF MUSCLES SUPPORTING BLADDER OR RECTUM

3. REDUCE DURATION OF SECOND STAGE OF LABOR WHEN THERE IS HYPERTENSION & FETAL DISTRESS 4. ENLARGE OUTLET, AS IN BREECH PRESENTATION OR FORCEPS DELIVERY

TYPES OF EPISIOTOMY
1. MEDIAN - FROM MIDDLE PORTION OF THE LOWER VAGINAL BORDER DIRECTED TOWARDS THE ANUS.

2. MEDIOLATERAL BEGINS IN THE MIDLINE BUT DIRECTED LATERALLY AWAY FROM THE ANUS.

Characteristics Midline Mediolateral Surgical repair Easy more difficult Faulty healing Rare more common Post op pain minimal common Blood loss less more Dyspareunia rare occasional Extensions more common uncommon Anatomical excellent occasional faulty results

.
e. APPLY THE MODIFIED RITGENS MANEUVER ** COVER THE ANUS WITH STERILE TOWEL & EXERT UPWARD & FORWARD PRESSURE ON THE FETAL CHIN. WHILE EXERTING GENTLE PRESSURE WITH TWO FINGERS ON THE HEAD TO

CONTROL EMERGING HEAD. THIS WILL NOT ONLY SUPPORT THE PERINEUM THUS PREVENTING LACERATIONS BUT WILL ALSO FAVOR FLEXION SO THAT THE SMALLEST SUBOCCIPITOBREGMATIC DIAMETER OF THE FETAL HEAD IS PRESENTED.
** EASE THE HEAD OUT IN-BETWEEN CONTRACTIONS & IMMEDIATELY WIPE THE NOSE & MOUTH OF SECRETIONS TO ESTABLISH A PATENT AIRWAY.

FORCEP DELIVERY OBSTETRICAL FORCEPS ARE DOUBLE BLADED INSTRUMENTS DESIGNED TO GRASP THE FETAL HEAD TO: 1. HASTEN DELIVERY WHEN THE LIFE OF THE MOTHER IS THREATENED. 2. TO SHORTEN THE SECOND STAGE OF LABOR

3. INTERVENE WHEN REGIONAL OR GENERAL ANESTHESIA HAS AFFECTED THE WOMANS ABILITY TO PUSH.

TYPES:
1. OUTLET FORCEP - USED WHEN THE HEAD IS VISIBLE IN THE PERINEUM. THIS IS ADVOCATED FOR DELIVERY OF PRETERM INFANTS. 2. MID FORCEP USED WHEN THE FETAL HEAD IS ABOVE THE ISCHIAL SPINES ( RARELY USED BECAUSE IT IS ASSOCIATED WITH CEREBRAL DAMAGE & NEONATAL DEPRESSION.)

NOTES:
a THE USE OF FORCEPS REQUIRES A FULLY DILATED CERVIX ( 10 CM) b. RUPTURED MEMBRANES c. VERTEX OR FACE PRESENTATION d. ENGAGED HEAD ( PREFERABLY IN THE PERINEUM THE PHYSICIAN MUST KNOW THE EXACT POSITION & STATION OF THE FETAL HEAD.)

NURSING CARE:
1.ENCOURAGE WOMAN TO MAINTAIN BREATHING TECHNIQUES & ASK NOT TO PUSH DURING APPLICATION OF FORCEPS. 2. MONITOR FHR CONTINUOUSLY UNTIL DELIVERY. FETAL BRADYCARDIA MAY OCCUR TEMPORARILY FROM HEAD COMPRESSION AS TRACTION IS APPLIED TO THE FORCEPS.

3. THE INFANT MAY HAVE A SCALP BRUISE FROM THE BLADES OF THE FORCEPS. PARENTS ARE TOLD OF THE BRUISE & ASSURED THAT IT WILL DISAPPEAR IN A FEW DAYS.
4. OBSERVE NEONATES FOR ERBS PALSY OR CEREBRAL TRAUMA.

C. THIRD STAGE OF LABOR = STAGE OF PLACENTAL EXPULSION

- BEGINS WITH THE DELIVERY OF THE INFANT TO THE DELIVERY OF THE PLACENTA. SIGNS OF PLACENTAL SEPARATION 1. CALKINS SIGN UTERUS BECOMING ROUND & FIRM & GLOBULAR AGAIN, RISING HIGH TO THE LEVEL OF THE UMBILICUS.

2. SUDDEN GUSH OF BLOOD FROM THE VAGINA 3. LENGTHENING OF THE CORD FROM THE VAGINA TYPES OF PLACENTAL DELIVERY: 1. SCHULTZ IF THE PLACENTA SEPARATES FIRST AT ITS CENTER & LAST AT ITS EDGES, IT TENDS TO FOLD ON ITSELF LIKE AN UMBRELLA & PRESENTS THE FETAL SURFACE WHICH IS SHINY. 80% OF PLACENTAS SEPARATE THIS WAY.

 SHINY FOR SCHULTZ

2. DUNCAN IF THE PLACENTA SEPARATES FIRST AT ITS EDGES, IT SLIDES ALONG THE UTERINE SURFACE & PRESENTS AT THE VAGINA WITH THE MATERNAL SURFACE WHICH IS RAW, RED, & IRREGULAR WITH THE RIDGES OR COTYLEDONS THAT SEPARATE BLOOD COLLECTION SPACES SHOWING. ONLY ABOUT 20% OF PLACENTAS SEPARATE THIS WAY. DIRTY FOR DUNCAN

NURSING CARE: 1.DO NOT HURRY THE EXPULSION OF THE PLACENTA BY FORCEFULLY PULLING OUT THE CORD OR DOING VIGOROUS FUNDAL PUSH ( CREDES MANEUVER) AS THIS CAN CAUSE UTERINE INVERSION.

2. TRACT THE CORD SLOWLY, WINDING IT AROUND THE CLAMP UNTIL THE PLACENTA SPONTANEOUSLY COMES OUT ,ROTATING IT SLOWLY SO THAT NO

MEMBRANES ARE LEFT INSIDE THE UTERUS. A METHOD CALLED BRANDT ANDREWS MANEUVER
3. TAKE NOTE OF THE TIME OF PLACENTAL DELIVERY. IT SHOULD BE DELIVERED WITHIN 15 TO 20 MINUTES AFTER THE DELIVERY OF THE BABY, OTHERWISE REFER IMMEDIATELY TO THE PHYSICIAN AS THIS CAN CAUSE SEVERE BLEEDING IN THE MOTHER. ** IF BLEEDING OCCURS & THE PLACENTA CANNOT BE DELIVERED, MANUAL EXTRACTION OF THE PLACENTA IS INDICATED **

4. INSPECT FOR COMPLETENESS OF COTYLEDONS; ANY PLACENTAL FRAGMENT RETAINED CAN ALSO CAUSE SEVERE BLEEDING & POSSIBLE DEATH. ( FIRST NURSING ACTION IN THE 3RD STAGE OF LABOR).

5. PALPATE THE UTERUS TO DETERMINE DEGREE OF CONTRACTION. IF RELAXED, BOGGY OR NON CONTRACTED; THE FIRST NURSING ACTION IS TO MASSAGE GENTLY & PROPERLY. AN ICE CAP OVER THE ABDOMEN WILL ALSO HELP CONTRACT THE UTERUS SINCE COLD CAUSES VASOCONSTRICTION.
6. INJECT OXYTOXICS, METHERGIN OR SYNTOCINON IM TO MAINTAIN UTERINE CONTRACTIONS, THUS PREVENT HEMORRHAGE.

NOTE: OXYTOXICS ARE NOT GIVEN BEFORE PLACENTAL DELIVERY BECAUSE PLACENTAL ENTRAPMENT COULD OCCUR. DO NOT GIVE METHERGIN IF BP IS 130/100 OR ABOVE.
7. INSPECT THE PERINEUM FOR LACERATIONS. ANYTIME THE UTERUS IS FIRM FOLLOWING PLACENTAL DELIVERY, YET BRIGHT RED VAGINAL BLEEDING IS GUSHING FORTH FROM THE VAGINAL OPENING, SUSPECT LACERATIONS.

CATEGORIES OF LACERATIONS
1.FIRST DEGREE INVOLVES THE FOURCHETTE, PERINEAL SKIN ,VAGINAL MUCUS MEMBRANES 2. SECOND DEGREE INCLUDES THE MUSCLES OF THE PERINEAL BODY. 3. THIRD DEGREE EXTENDS TO THE ANAL SPHINCTER 4. FOURTH DEGREE EXTENDS TO THE MUCOSA OR LUMEN OF THE RECTUM.

Cesarean Birth

Immediate preoperative care Informed consent Hygiene GI tract preparation Baseline intake and output Hydration Preoperative medication Checklist Transport Role of support person

Intraoperative care
Anesthesia Skin

preparation Surgical incision

Types of incisions
Birth

Postpartal care
Pain control Fluid volume Output Circulation Parenting Infection

 fetus is delivered through an incision in anterior abdominal and uterine wall

Indications: Cephalopelvic disproportion Fetal malpresentation non reassuring EFM strip

Uterine Incisions 1. Low segment Transverse - incision is made in the non contractile portion of the uterus - low chance of uterine rupture, may have trial of labor - fetus must be in longitudinal lie 2. Classical - incision is made in the contractile portion of the uterus - risk uterine rupture - lower segment varicosities and myomas can be bypassed

LOW TRANSVERSE CS: ADVANTAGES: 1. INVOLVES LESS BLOOD LOSS

2. LESS POSSIBILITY OF RUPTURE OF CS SCAR DURING SUBSEQUENT

PREGNACY 3.INCISION IS EASIER TO REPAIR 4. LESS INCIDENCE OF POSTOPERATIVE COMPLICATIONS: INFECTION, ADHESION OF BOWEL TO THE INCISIONAL LINE, INTESTINAL OBSTRUCTION. 5. ALLOWS A VAGINAL DELIVERY AFTER A PREVIOUS CESARIAN SECTION.(VBAC)

LOW TRANSVERSE CS: DISADVANTAGES

1.DIFFICULT & LONGER TO PERFORM THAN THE CLASSICAL TYPE. 2. NOT RECOMMENDED WITH ANTERIOR PLACENTA PREVIA

2. CLASSICAL TYPE
- A VERTICAL INCISION IS MADE DIRECTLY INTO THE WALLS OF THE CORPUS, WHICH IS THE MOST CONTRACTILE PORTION. ADVANTAGES: 1.EASIEST & QUICKEST INCISION TO PERFORM

2. RAPID EXTRACTION OF FETUS CAN BE DONE.

CLASSICAL CS: DISADVANTAGES

1. INVOLVES MORE BLOOD LOSS BECAUSE INCISION IS MADE ON THE

THICK VASCULAR PORTION OF THE UTERUS 2. HIGHER INCIDENCE OF POST-OP COMPLICATIONS 3. RUPTURE OF CS SCAR ON SUBSEQUENT PREGNANCY IS MORE LIKELY. 4.INVOLVES MORE HEALING DISCOMFORT & A WIDER CS SCAR.

PORROS OPERATION / CESARIAN HYSTERECTOMY:

- HYSTERECTOMY ( REMOVAL OF THE UTERUS) IS PERFORMED AFTER CESARIAN SECTION. INDICATIONS: 1.INTRAUTERINE INFECTION 2.UTERINE RUPTURE THAT CANNOT BE REPAIRED 3.PLACENTA ACCRETA

4. PRESENCE OF LARGE UTERINE MYOMAS

5. HYPOTONIC UTERUS THAT DOES NOT RESPOND TO OXYTOCIN 6.GROSSLY DEFECTIVE SCAR

7. LACERATIONS OF MAJOR UTERINE VESSELS.

NURSING CARE:
** CARE AFTER A CESARIAN BIRTH INCLUDES BOTH OPERATIVE & POSTPARTUM CARE.

Complications:
hemorrhage
Infection Visceral injury Thrombosis

Most popular: Regional block Epidural Spinal anesthesia Because the mother is awake and aware of the birth of her infant When time is of the essence or when an epidural or spinal cannot be used, general anesthetic is used.

Scheduled Cesarean Birth - If it is to be a repeat cesarean birth (eg, cephalopelvic disproportion) - If labor is contraindicated (eg, complete placenta previa, hydrocephaly) - If labor cannot be induced and birth is necessary Clients have some time to prepare for the cesarean birth

Unscheduled/ Emergency Cesarean Birth Usually a result of some difficulty in the labor process/ failure to progress in labor Placenta previa Abruptio placenta Fetal distress

Vaginal Birth after Cesarean (VBAC) When the reason for the initial cesarean is a nonrecurring situation such as placenta previa, prolapsed cord, or breech presentation, the client may be able to have a vaginal birth with the next pregnancy Low transverse uterine incision: trial of labor is recommended Classic uterine incision: trial of labor is CI

D. FOURTH STAGE OF LABOR STAGE OF PUERPERIUM / STAGE OF VIGILANCE

-SAID TO BE THE MOST CRITICAL FOR THE MOTHER BECAUSE OF UNSTABLE VITAL SIGNS.

= STARTS IMMEDIATELY AFTER THE DELIVERY OF THE FETUS UP TO 4 HOURS & IS COMPLETED WHEN THE REPRODUCTIVE TRACT HAS RETURNED TO ITS NON PREGNANT CONDITION

COMPLICATIONS OF LABOR 1. DYSTOCIA PROLONGED & DIFFICULT LABOR ( LABOR THAT LASTS MORE THAN 24 HOURS). CAUSES:

A. ABNORMALITIES OF THE POWER / UTERINE DYSFUNCTION

a. HYPOTONIC UTERINE CONTRACTION WEAK & INFREQUENT CONTRACTIONS WHICH ARE INSUFFICIENT TO DILATE THE CERVIX. USUALLY OCCURS DURING THE ACTIVE PHASE

CAUSES:
1. OVERDISTENTION OF THE UTERUS 2. PELVIC BONE CONTRACTION 3. UNRIPE OR RIGID CERVIX 4. CONGENITAL ANOMALIES OF THE UTERUS.

MX:
1. REEVALUATE PELVIC SIZE TO RULE OUT FETOPELVIC DISPROPORTION

2. AMNIOTOMY IF MEMBRANES ARE NOT YET RUPTURED

3. AUGMENT LABOR BY OXYTOCIN ADMINISTRATION 4. IF CONTRACTED PELVIS IS THE CAUSE, CS IS PERFORMED.

b. HYPERTONIC UTERINE CONTRACTIONS

- CONTRACTIONS THAT ARE TOO FREQUENT BUT UNCOORDINATED, THE UTERUS DOES NOT RELAX COMPLETELY IN BETWEEN CONTRACTIONS & CONTRACTIONS ARE MORE PAINFUL BUT INEFFECTIVE. MX: SIDE LYING POSITION TO MAXIMIZE BLOOD FLOW TO THE FETUS & THE PLACENTA.

2. PRECIPITATE LABOR / PRECIPITATE BIRTH:

-labor lasting < 3 hrs from the onset of contractions to the birth of infant MATERNAL COMPLICATIONS: 1.increase risk of uterine rupture 2. laceration of cervix, vagina and perineum 3. postpartum hemorrhage FETAL COMPLICATION: 1.hypoxia

PUERPERIUM / POSTPARTUM = REFERS TO THE SIX TO EIGHT WEEK PERIOD AFTER THE DELIVERY OF THE BABY. INVOLUTION = THE RETURN OF THE REPRODUCTIVE ORGANS TO THEIR PREPREGNANT STATE.( 6 WEEKS)

B breasts U terus B owel B ladder L ochia E pisiotomy S ex / skin

H omans sign
E motional status of the mother

POSTPARTUM PSYCHOLOGICAL ADAPTATION:RUBIN

1. TAKING- IN PHASE = 1 3 DAYS POSTPARTUM WHEN MOTHER RELIES ON OTHERS TO CARE FOR HER & HER NEWBORN.PREOCCUPIED WITH SELF & OWN NEEDS ( FOOD & SLEEP), CLIENT MAY VERBALIZE HER FEELINGS REGARDING RECENT DELIVERY. HESITANT ABOUT MAKING DECISIONS.

2. TAKING HOLD PHASE = 4 7 DAYS POSTPARTUM WHEN MOTHER BEGINS TO INITIATE ACTIONS & DECISIONS; DEPENDENCY /INDEPENDENCY; READY FOR MOTHERING ROLE; BEST TIME TO TEACH INFANT CARE & MOTHERING ; POSTPARTUM BLUES (AN OVERWHELMING FEELING OF SADNESS THAT CANNOT BE ACCOUNTED FOR) MAY BE OBSERVED. COULD BE DUE TO HORMONAL CHANGES, FATIGUE OR FEELINGS OF INADEQUACY IN TAKING CARE OF A NEW BABY.

MX:
- EXPLAIN THAT IT IS NORMAL & THAT CRYING COULD BE THERAPEUTIC. BUT IF POSTPARTUM BLUES EXTEND BEYOND TWO WEEKS, IT COULD LEAD TO POSTPARTUM DEPRESSION & POSTPARTUM PSYCHOSIS ;THEREFORE CONSTANT MONITORING SHOULD BE DONE TO THE MOTHER. IMPLICATION: PROVIDE PSYCHOLOGICAL SUPPORT .

3. LETTING GO PHASE = 10 DAYS

- WOMAN ATTAINS COMPLETE INDEPENDENCE; ASSUMING NEW ROLES AND RESPONSIBILITIES

may Experience grief for relinquished roles; adjustment to accommodate for infant in family

BLOOD PRESSURE TAKEN EVERY 15 MINUTES FOR 1ST HR; THEN EVERY 30 MINUTES DURING THE 2ND HOUR

ROOMING IN CONCEPT ( PRIMARILY TO PROMOTE BONDING).

GENITAL CHANGES UTERINE INVOLUTION IS ASSESSED BY MEASURING THE FUNDIC HEIGHT BY FINGERBREADTHS (=1 CM). ON POSTPARTUM DAY 1 ( PPD 1) = FUNDUS IS ONE FINGERBREADTH BELOW THE UMBILICUS; ON PPD 2, 2 FINGERBREADTHS BELOW THE UMBILICUS & SO FORTH UNTIL ON DAY 10, IT CAN NO LONGER BE PALPATED BECAUSE IT IS ALREADY BEHIND THE SYMPHYSIS PUBIS.

AFTERPAINS / AFTERBIRTH PAINS = STRONG UTERINE CONTRACTIONS FELT MORE PARTICULARLY BY MULTIS,THOSE WHO DELIVERED LARGE BABIES, & THOSE WHO BREASTFEED BECAUSE OF OXYTOCIN PRODUCTION. IT WILL BE RELIEVED IN 3 -4 DAYS.
may be relieved by lying on abdomen with small pillow, heat, ambulation, mild analgesic (if breast feeding, 1 h before nursing)

B breasts U terus

B owel
B ladder

L ochia
E pisiotomy S ex / skin H omans sign E motional status of the mother

1. Breasts progress from soft filling with potential for engorgement (vascular congestion related to increased blood and lymph supply; breasts are larger, firmer, and painful) Non-nursing woman suppress lactation Mechanical methods tight-fitting brassiere, ice packs, minimize breast stimulation Nursing woman successful lactation is dependent on infant sucking and maternal production and delivery of milk (letdown/milk ejection reflex); monitor and teach preventive measures for potential problems

Engorgement nurse frequently (every -3 h) and long enough to empty breasts completely (evidenced by sucking without swallowing) warm shower or compresses to stimulate letdown alternate starting breast at each feeding mild analgesic 20 min before feeding and ice packs between feedings for pronounced discomfort

Expression of breast milk to collect milk for supplemental feedings to relieve breast fullness or to build milk supply may be manually expressed or pumped by a device and refrigerated for no more than 48 h ; or frozen in plastic bottles in refrigerator freezer for 2 wk; and deep freezer for 2 months (do not thaw in microwave or on stove)

Length of feeding Varies with each mother /infant unit

BURPING-

Cradling

ALL INFANTS REQUIRE BURPING ( MIDWAY AND AFTER FEEDING) TO EXPEL THE AIR SWALLOWED WHEN THE INFANT SUCKS SOME INFANT SWALLOW MORE AIR THAN OTHERS AND REQUIRE MORE FREQUENT BURPING

Feed the infant on demand--on "hunger cues. Listen and feel for infant's swallowing. Infant should regain birth weight by two weeks of age. Avoid nipple confusion by adopting this policy: three to four weeks of exclusive breastfeeding, then no more than one bottle a day, using expressed breast milk. Count wet diapers: one on day 1, two on day 2, three on day 3, six per day from day 6 on, with three or more stools per day. Report any signs and symptoms of dehydration and jaundice Expect weight loss of <8 percent at the two- to four-day follow-up visit.

2. UTERUS - FUNDUS OF THE UTERUS SHOULD BE FIRM, IN THE MIDLINE, & DURING THE FIRST 12 HOURS POST PARTUM, IS A LITTLE ABOVE THE UMBILICUS.

3. BLADDER = A FULL BLADDER IS

EVIDENCED BY A FUNDUS WHICH IS RIGHT TO THE MIDLINE

GI bowel sluggishness, decreased abdominal muscle tone, perineal discomfort may lead to constipation; managed by: early ambulation, increased dietary fiber and hydration, stool softeners

5. LOCHIA UTERINE DISCHARGE CONSISTING OF BLOOD, DECIDUAS, WBC & MUCUS. SHOULD BE MODERATE IN AMOUNT.

PATTERN OF LOCHIA:
1.RUBRA = 0-3 DAYS , DARK RED & MODERATE IN AMOUNT, SMALL CLOTS, FLESHY STALE ODOR. 2. SEROSA = 4 -7 DAYS ; PINK OR BROWNISH IN COLOR, NO CLOTS, NO ODOR ( UNLESS POOR HYGIENE) 3. ALBA = 1 3 WEEKS; CREAM TO YELLOWISH IN COLOR; MINIMAL IN AMOUNT; NO ODOR; NO CLOTS

NOTES ON LOCHIA:
a.PATTERN SHOULD NOT REVERSE

b. IT SHOULD APPROXIMATE MENSTRUAL FLOW

c. IT HAS THE SAME FLESHY ODOR AS MENSTRUAL BLOOD. d. IT SHOULD NEVER BE ABSENT, REGARDLESS OF THE METHOD OF DELIVERY. ( NSD OR CS)

possible discomfort swelling and/or ecchymosis Managed with analgesics and/or topical anesthetics, ice packs for first 12-24 h and then 20 min sitz baths 3-4 times/d, tightening buttocks before sitting Monitor episiotomy/laceration teach techniques to prevent infection, e.g., change pads on regular basis, peri care (cleaning from front to back using peri-bottle or surgigator after each voiding and bowel movement), and sitz baths

abstain from intercourse until episiotomy is healed and lochia has ceased (usually 3-4 wk) may be affected by fatigue, fear of discomfort, leakage of breast milk, concern about another pregnancy assess and discuss couples desire for and understanding about contraceptive methods breastfeeding does not give adequate protection oral contraceptives should not be used during breastfeeding (CONDOM only)

1. Postpartum Hemorrhage is the leading cause of maternal mortality. Blood loss of more than 500 ml is considered hemorrhage. The most dangerous time at which hemorrhage is likely to occur is during the first hour postpartum

Early postpartum hemorrhage occurs during the first 24 hrs after delivery

Causes:
. Uterine atony Laceration of the birth canal Inversion of the uterus

Late postpartum hemorrhage occurs from 24 hrs after birth until 4 weeks postpartum

Most common cause of EARLY postpartum hemorrhage. When the uterus fails to contract, open blood vessels in the placental site continue to bleed resulting in hemorrhage.

Overdistention of the uterus hydramnios, multiple pregnancy Complication of labor precipitate, prolonged labor High parity & advanced maternal age Presence of fibroid tumors Overmassage of the uterus Retained placental fragments

First action taken when uterus is relaxed & boggy is to MASSAGE IT GENTLY. Keep bladder empty since a full bladder interferes with effective uterine contractions Monitor vital signs & amount of blood loss during the early postpartal period Administer oxytocin if uterus is not contracted BT & IVF to replace blood loss If retained placental fragments is the cause, curettage is performed If bleeding cannot be controlled by the above measures, HYSTERECTOMY is performed as the last resort.

Uterus will not be able to contract effectively if placental fragments are retained resulting in uterine atony & hemorrhage. Most common cause of LATE postpartum hemorrhage.

Partial separation of a normal placenta Manual removal of the placenta Entrapment of placenta in the uterus Abnormal adherent placenta acreta, increta, percreta

D & C to remove adherent placenta Hysterectomy for severe cases

Occurs when there is a delay in the return of the uterus to its prepregnant size, shape & function Causes: Retained placental fragments Infection Endometritis Uterine tumors

SSx: Enlarged & boggy uterus Prolonged lochial discharge persistent lochia rubra Backache Management: Methergin to stimulate uterine contractions .2 mg 4x/day for 3 days Antibiotics to prevent or treat infection D & C if there are retained fragments Instruct woman to report the following signs fever, vaginal bleeding, passage of tissue

*** IMMEDIATE MEDICAL INTERVENTION IS NECESSARY IF ANY OF THE FOLLOWING OCCURS: 1. MARKED BLEEDING PERSISTS BLOOD SOAKS A PERINEAL PAD IN 15 MINUTES REGARDLESS OF WHETHER THE BLEEDING IS ACCOMPANIED BY A CHANGE IN VITAL SIGNS, MATERNAL COLOR OR BEHAVIOR. 2. COMPLAINTS OF LIGHTHEADEDNESS & BLURRING OF VISION.

3. ASHEN COLOR / PALLOR

4. EXHIBITS AIR HUNGER 5. COLD CLAMMY SKIN 6. RESTLESSNESS 7. DECREASED BLOOD PRESSURE 8. INCREASED BLOOD PRESSURE 9. INCREASED PR & RR

EMERGENCY MX & INTERVENTION:

1. CALL FOR HELP

2. TURN WOMAN TO HER LEFT & CHECK FUNDUS OF THE UTERUS FOR FIRMNESS 3. INCREASE IV FLOW & ADD OXYTOCIN AS PER DOCTORS ORDER

4. ELEVATE THE FOOT PART OF THE BED TO ALLOW THE FAST RETURN OF THE BLOOD TO THE UPPER PART OF THE BODY
5. ADMINISTER OXYGEN

DANGER SIGNS OF PREGNANCY 1. VAGINAL BLEEDING = VAGINAL BLEEDING SHOULD BE REPORTED IMMEDIATELY FOR FURTHER EVALUATION 2. PERSISTENT VOMITING ( HYPEREMESIS GRAVIDARUM) = NAUSEA & VOMITING THAT CONTINUES PAST THE 12 WEEK OF PREGNANCY IS EXTENDED VOMITING. IT DEPLETES THE NUTRITIONAL SUPPLY AVAILABLE TO THE FETUS.

3. CHILLS & FEVER = MAY BE EVIDENCE OF INTRAUTERINE INFECTION WHICH IS A SERIOUS COMPLICATION FOR BOTH THE

WOMAN & THE BABY.

4. SUDDEN ESCAPE OF FLUID FROM THE VAGINA = MEANS THAT THE MEMBRANES HAVE RUPTURED. BOTH THE MOTHER & THE FETUS ARE THREATENED BECAUSE UTERINE CAVITY IS NO LONGER SEALED AGAINST INFECTION.
** IF FETUS IS SMALL & HIS HEAD DOES NOT FIT INTO THE CERVIX, THE UMBILICAL CORD MAY PROLAPSE WITH THE RUPTURED MEMBRANE , THE HEAD MAY BE COMPRESSED AGAINST THE CORD. ANOTHER DANGEROUS COMPLICATION IS ASCENDING INFECTION.

5. ABDOMINAL OR CHEST PAINS = ABDOMINAL PAINS MAY MEAN TUBAL PREGNANCY THAT HAVE RUPTURED, SEPARATION OF THE PLACENTA, PRETERM LABOR WHILE CHEST PAINS MAY INDICATE PULMONARY EMBOLUS THAT FOLLOWS THROMBOPHLEBITIS.
6. ABSENCE OF FETAL HEART SOUNDS AFTER THEY HAVE INITIALLY BEEN AUSCULTATED ON THE 4TH & 5TH MONTH ( MAY INDICATE INTRAUTERINE FETAL DEATH - IUFD)

7. SWELLING OF THE FACE & FINGERS = EDEMA

8. FLASHES OF LIGHTS OR DOTS ( SCOTOMA) 9. BLURRING OF VISION 10. SEVERE HEADACHE & DIZZINESS ** MAY MEAN SIGNS OF PREGNANCY INDUCED HYPERTENSION

Teratogen any factor, chemical or physical that adversely affects the fertilized ovum, embryo or fetus Can involve either sexually transmitted or systemic infections T Toxoplasmosis O other infections ( syphilis, HepaB, HIV) R Rubella C Cytomegalovirus ( CMV) H Herpes Simplex virus

Damage on the fetus includes deafness, mental and motor challenges, cataracts, cardiac defects ( PDA and pulmonary stenosis) retarded intrauterine growth ( SGA) dental and facial clefts ( cleft lip & palate) Rubella titer greater than 1:8 suggests immunity to rubella Rubella titer less than 1:8 suggests that the woman is susceptible to the virus Titer that is greatly increased over a previous reading or initially high suggests that a recent infection has occurred.

CA herpes virus Droplet transmission from person to person Effects on the infant includes:

Neurological challenge ( hydrocephalus, microcephalus, spasticity, ) with eye damage ( optic atrophy, deafness, liver disease No tx

Systemic involvement ( Viremia) and crosses the placenta to the fetus. 1st tri- severe congenital anomalies or spontaneous miscarriage 2nd tri & 3rd tri- premature birth, IUG retardation and continuing infection of the newborn at birth Tx; IV or oral Acyclovir (Zovirax) during pregnancy

High risk pregnancy is one in which a concurrent disorder, pregnancy related complication, or external factor jeopardizes the health of the mother, the fetus or both. Isoimmunization the production of antibodies against Rh(+) blood by the immunologic system Tocolytic a drug that halts labor ( stops uterine contractions by relaxing smooth muscles)

BLEEDING COMPLICATIONS IN PREGNANCY First Trimester ( 1-3 months) Second Trimester ( 4-6 mos) Third Trimester ( 7-9 mos) Abortion Ectopic Pregnancy Hydatidiform Mole Incompetent Cervix Abruptio/Ablatio Placenta Placenta Previa Preterm Labor

HYPERTENSIVE DISORDERS IN PREGNANCY Gestational Hypertension Chronic Hypertension Pregnancy Induced Hypertension Pre-eclampsia Eclampsia

HeLLP Syndrome

METABOLIC DISORDER IN PREGNANCY Gestational Diabetes Mellitus MEDICAL CONDITIONS COMPLICATING PREGNANCY Heart Disease

Advanced age of 35 yrs and above is a high risk pregnancy Teenage pregnancy of 16 years and below is considered a high risk pregnancy

Parity First pregnancy is the period of highest risk Second / Third and Fourth pregnancy the risk of death for the mother is at its lowest Fifth pregnancy marked increase especially when the pregnant mother is over 40 years of age.

COMPLICATIONS OF PREGNANCY A.FIRST TRIMESTER BLEEDING: 1. ABORTION - THE EXPULSION OF THE PRODUCTS OF CONCEPTION BEFORE THE AGE OF VIABILITY ( FETUS CAN SURVIVE EXTRAUTERINE LIFE) - FETUS IS LESS THAN 20 WEEKS ( 24 weeks in the US) OR LESS THAN 500 GRAMS

CAUSES OF ABORTION:
1. ABNORMALITY IN THE GERM PLASMA

2.ABNORMALITY IN THE IMPLANTATION PROCESS

3. TRAUMA PSYCHOLOGICAL, PHYSICAL 4. HORMONAL IMBALANCE ( LOW PROGESTERONE)

5. INTAKE OF DRUGS QUININE, ASPIRIN

6. INFECTIOUS DISEASES GERMAN MEASLES, PTB, HERPES

7. PRESENCE OF VENEREAL DISEASES 8. ABNORMALITY IN THE REPRODUCTIVE SYSTEM

8. SEVERE MALNUTRITION
EARLY ABORTION

HAPPENS BEFORE 16 WEEKS

LATE ABORTION HAPPENS BETWEEN 16 20 WEEKS

Types of Abortion: SPONTANEOUS = UNINTENDED TERMINATION OF PREGNANCY AT ANY TIME BEFORE THE FETUS HAS ATTAINED VIABILITY. THREATENED POSSIBLE LOSS OF THE PRODUCTS OF CONCEPTION S/SX: SLIGHT BLEEDING; MILD UTERINE CRAMPING BUT NO CERVICAL DILATATION ON VAGINAL EXAMINATION;NO PASSAGE OF TISSUE

INEVITABLE OR IMMINENT ABORTION is a loss of pregnancy that cannot be prevented. Clinical Manifestations: Moderate to profuse Bleeding Moderate to severe uterine cramping Cervix dilated Membranes rupture

TYPES OF INEVITABLE ABORTION:

Complete all products of conception are expelled. Sxs of complete abortion: Moderate bleeding Mild uterine cramping Passage of tissue
1)

2) Incomplete not all products of conception are expelled from the uterus. Signs and Sxs: Profuse vaginal bleeding Severe uterine cramping Open cervix Passage of tissue Other products are retained

Missed miscarriage
Retention of all products of conception after the death of the fetus in the uterus S/Sx: - No FHT - Signs of pregnancy disappear Management: D&C

Septic Abortion

Abortion complicated by infection

S/Sx: - Foul smelling vaginal dischrage - Uterine cramping - Fever Management: - Treat abortion - Antibiotics

HABITUAL OR RECURRENT PREGNANCY LOSS SPONTANEOUS ABORTION IN THREE OR MORE SUCCESSIVE PREGNANCIES USUALLY DUE TO INCOMPETENT CERVIX.

Induced Abortion is an intentional loss of pregnancy through direct stimulation either by chemical or mechanical means. Types of induced abortion: 1) Therapeutic abortion to preserve the life of the mother 2) Elective abortion
B.

2. ECTOPIC PREGNANCY
- ANY PREGNANCY THAT OCCURS OUTSIDE THE UTERINE CAVITY. --SECOND LEADING CAUSE OF BLEEDING IN EARLY PREGNANCY.

TYPES:
1.AMPULAR 4. CERVICAL

2. INTESTINAL
3. OVARIAN

5. ABDOMINAL

Predisposing causes: Salpingitis or PID Previous ectopic pregnancy Tumors that distort the tubes External migration of the ovum Intrauterine device (IUD) Adhesion of the fallopian tube from a previous infection Scars from tubal surgery

s/sx of ectopic pregnancy: Vaginal spotting or bleeding Cul de sac mass Signs of tubal rupture: Severe sharp knife like pain ( stabbing) in the lower quadrant of the abdomen Abdominal rigidity Sharp localized pain in the cervix on internal examination

Signs of hemorrhage: - Cullens sign bluish discoloration of the umbilicus due to the presence of blood in the peritoneal cavity -Hard or rigid board-like abdomen - signs of shock

Culdocentesis aspiration of bloody fluid from Cul de sac of Douglas Ultrasound reveals presence of the gestational sac outside of the uterine cavity

Prevent and treat hemorrhage which is the main danger of ectopic pregnancy.

Blood transfusion Place patient flat in bed with legs elevated Monitor Vital signs, I & O, & amount of blood loss

Prevent infection as the woman who lost so much blood is susceptible to infection Contraception must be started upon discharge from hospital. Ovulation begins as early as 19 days or 3 weeks after resection of ectopic pregnancy.

B. SECOND TRIMESTER BLEEDING

1. GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE OR HMOLE)) - is a mass of abnormal rapidly growing trophoblastic tissue in which avascular vesicles hang in grapelike clusters THAT PRODUCE LARGE AMOUNTS OF HCG.

Predisposing factors: cause is unknown 17 years old below and 35 yrs. Above Low protein intake Previous mole Higher incidence in Asian women

TYPES: 1.COMPLETE MOLE LACKS AN EMBRYO OR FETUS ( NO FETAL BLOOD) 2. PARTIAL MOLE INVOLVES A CHROMOSOMALLY ABNORMAL EMBRYO OR FETUS.( WITH FETAL BLOOD) - 69 XXX or 69 XXY

CAUSES:
1. SPERM + OVUM + DUPLICATION =46 (COMPLETE ( 23) ( 0) MOLE) =69 (PARTIAL MOLE)

2. SPERM + OVUM (46) 3. SPERM ( 23) + OVUM + ( 23) (23)

=69 (PARTIAL

SPERM
( 23)

MOLE)

Signs and Sxs: Rapid increase in uterine size greater than gestational age of the fetus Marked increase HCG titer; NV:400,00 iu Excessive nausea and vomiting due to elevated HCG Brownish vaginal discharge around 4th month containing grapelike vesicles No FHT is detected after 10 to 12 weeks, no fetal movement after 18-20 weeks No fetal parts Bleeding which may vary from spotting to profuse hemorrhage and is usually brownish but may be bright red No fetal skeleton

Hypertension & other sx of preeclampsia Symptoms of PIH before 24th week gestation

**difference bet.H-mole & pre-eclampsia - before 20 weeks =H mole - after 20 weeks up to 2 weeks post partum = preeclampsia

DX: Ultrasound will identify the characteristic vesicles.

Treatment and management: D and C or D & E to remove the mole. ( If the woman is more than 40 yrs old, hysterectomy is done since she has a higher chance of developing CHORIOCARCINOMA Monitor HCG for 1 year ( HCG shld be negative 2-6 weeks after removal of H-mole.)

Chest X ray every 3 mos for 6 mos. The lungs are the most common site of metastasis of choriocarcinoma Chemotherapy ( Methotrexate) if: -HCG titers are increased for 3 consecutive weeks or double at anytime -HCG titers remain elevated 3-4 mos. after delivery

The woman is advised not to get pregnant for 1 year, contraceptive method should NOT be the pills. Pills contain estrogen which promote regrowth of the chorionic villi. Use mechanical equipments against pregnancy Ex. Condom Hysterectomy is the method of tx for women above 40 yrs old because of the higher incidence of malignancies & to clients who have completed childbearing & require sterilization.
*** Management of all trophoblastic tumors is HYSTERECTOMY ****

2. INCOMPETENT CERVIX OR PREMATURE CERVICAL DILATATION:

- PAINLESS CERVICAL EFFACEMENT & DILATATION IN EARLY MIDTRIMESTER RESULTING IN EXPULSION OF PRODUCTS OF CONCEPTION.
- MOST COMMON CAUSE OF HABITUAL ABORTION

CAUSES:
1.INCREASED MATERNAL AGE 2. CONGENITAL MALDEVELOPMENT OF THE CERVIX short cervix 3. TRAUMA TO THE CERVIX ( HISTORY OF REPEATED D & CS; CERVICAL LACERATIONS WITH PREVIOUS PREGNANCIES )

Signs and Sxs: Presence of uterine contractions in midtrimester Rupture of the bag of waters Expulsion of the conceptus Presence of painless cervical dilatation Relaxed cervical os on pelvic examination

MX: 1. CERVICAL CERCLAGE MEDICAL MANAGEMENT WHEREIN THE PHYSICIAN SUTURES A CERTAIN PART OF THE CERVIX BETWEEN 14 AND 16 WEEKS GESTATION TO PREVENT CERVICAL DILATATION.

a.MCDONALDS NYLON SUTURES ARE PLACED HORIZONTALLY & VERTICALLY ACROSS THE CERVIX & PULLED TIGHT TO REDUCE THE CERVICAL CANAL TO A FEW MILLIMETERS IN DIAMETER.
b. SHIRODKAR STERILE TAPE IS THREADED IN A PURSE-STRING MANNER UNDER THE SUBMUCUS LAYER OF THE CERVIX & SUTURED IN PLACE TO ACHIEVE A CLOSED CERVIX.

Cervix not dilated Intact membranes No vaginal bleeding & uterine cramping

C. THIRD TRIMESTER BLEEDING

1.PLACENTA PREVIA

- LOW IMPLANTATION OF THE PLACENTA

TYPES: 1. LOW-LYING IMPLANTATION OF THE PLACENTA IN THE LOWER RATHER THAN IN THE UPPER PORTION OF THE UTERUS

2. MARGINAL PLACENTA EDGE APPROACHES THAT OF THE CERVICAL OS 3.PARTIAL IMPLANTATION THAT OCCLUDES A PORTION OF THE CERVICAL OS
4. COMPLETE ( TOTALIS) PLACENTA THAT TOTALLY OBSTRUCTS THE CERVICAL OS

Predisposing factors: Multiparity Advanced maternal age over 35 yo Multiple pregnancy Uterine tumor Scarring from previous previous CS Decreased vascularity of upper uterine segment Past uterine D&C

Signs and Sxs: Painless, bright red vaginal bleeding during the 3rd trimester Abdomen soft, non tender Ultrasound reveals placenta previa

NURSING MANAGEMENT:

1. MONITOR VITAL SIGNS & BLEEDING ( WEIGH UNUSED PERINEAL PAD, THEN WEIGH PERINEAL PAD SOAKED IN BLOOD, THEN SUBTRACT. THE DIFFERENCE IS THE WEIGHT OF THE BLOOD LOSS.)

2.PROVIDE STRICT BED REST TO MINIMIZE THE RISK TO FETUS.( CBR without BRPs ) 3.OBSERVE FOR FURTHER BLEEDING EPISODES.( PREPARE FOR BT) ( Hgb & Hct) 4. AVOID VAGINAL EXAMINATIONS ( NO IE). IF IE IS INDICATED, IT SHOULD BE DONE IN A DOUBLE SET-UP ENVIRONMENT. ( MEANING: the DR is prepared for vaginal exam and for cesarean birth in case the examination precipitates profuse bleeding) WHEREIN THE PATIENT HAS ALREADY SIGNED A CONSENT FORM, PRE-OP

MEDS HAVE BEEN GIVEN, ABDOMINAL PREP HAS BEEN DONE SO THAT IF THE PLACENTA IS ACCIDENTALLY DETACHED BECAUSE OF MANIPULATIONS, CS CAN BE DONE IMMEDIATELY.
5. ASSESS FETAL LUNG MATURITY 6. OBSRVE STRICT ASEPTIC TECHNIQUE 7. OBSERVE PP HEMORRHAGE 8. PROVIDE EMOTIONAL SUPPORT DURING THE GRIEVING PROCESS.

**** CLASSICAL CESARIAN SECTION (UTERUS IS INCISED IN THE VERTICAL

SEGMENT) IS DONE IN CASE OF SEVERE BLEEDING.**

Complications of placenta previa: Hemorrhage Infection Prematurity

** BLEEDING WITH PLACENTA PREVIA OCCURS WHEN THE LOWER UTERINE SEGMENT BEGINS TO DIFFERENTIATE FROM THE UPPER SEGMENT LATE IN PREGNANCY ( APPROXIMATELY WEEK 30 because of uterine contractions ) & THE CERVIX BEGINS TO DILATE. THE BLEEDING PLACES THE MOTHER AT RISK FOR HEMORRHAGE. BECAUSE THE PLACENTA IS LOOSENED, THE FETAL OXYGEN MAY BE COMPROMISED

IMMEDIATE CARE MEASURES:

** TO ENSURE AN ADEQUATE BLOOD SUPPLY TO THE MOTHER & FETUS, PLACE THE WOMAN ON BED REST IN A LEFT SIDE LYING POSITION.( LLP)**

2. ABRUPTIO PLACENTA

- ABRUPT SEPARATION OF AN OTHERWISE NORMALLY IMPLANTED PLACENTA AFTER 20 WEEKS AOG.

TYPES: 1.MARGINAL ( OVERT) SEPARATION BEGINS AT THE EDGES OF THE PLACENTA ALLOWING BLOOD TO ESCAPE FROM THE UTERUS. BLEEDING IS EXTERNAL.

2. CENTRAL ( COVERT)
PLACENTA SEPARATES AT THE CENTER RESULTING IN BLOOD BEING TRAPPED BEHIND THE PLACENTA. BLEEDING THEN IS INTERNAL AND NOT OBVIOUS.

CAUSES: 1.MATERNAL HYPERTENSION ( CHRONIC OR PREGNACY INDUCED)

2. ADVANCED MATERNAL AGE

3. GRAND MULTIPARITY MORE THAN 5 PREGNANCIES 4. TRAUMA TO THE UTERUS

S/SX:
1. SHARP PAIN IN THE FUNDAL AREA AS THE PLACENTA SEPARATES 2.PAINFUL DARK RED VAGINAL BLEEDING IN COVERT TYPE 3.PAINFUL BRIGHT RED VAGINAL BLEEDING IN OVERT TYPE

4.HARD, RIGID, FIRM,BOARD-LIKE ABDOMEN CAUSED BY ACCUMULATION

OF BLOOD BEHIND THE PLACENTA WITH FETAL PARTS HARD TO PALPATE.

5. ABNORMAL TENDERNESS DUE TO DISTENTION OF THE UTERUS WITH BLOOD.

6. SIGNS OF SHOCK & FETAL DISTRESS AS THE PLACENTA SEPARATES.

MX:
1. WHEN PLACENTA ABRUPTIO IS SUSPECTED OR DIAGNOSED, HOSPITALIZATION IS A MUST. 2. BEDREST OR SIDE LYING POSITION FOR OPTIMUM PLACENTAL PERFUSION. 3. MONITOR VITAL SIGNS, FHT, AMOUNT OF BLOOD LOSS GIVE MASK O2 IF FETAL DISTRESS IS PRESENT.

4. DELIVERY:
** VAGINAL DELIVERY IF THERE IS NO SIGN OF FETAL DISTRESS, BLEEDING IS MINIMAL & VITAL SIGNS ARE STABLE. ** CESARIAN DELIVERY IF BLEEDING IS SEVERE, FETAL DISTRESS IS PRESENT & FETUS CANNOT BE DELIVERED IMMEDIATELY WITH VAGINAL METHOD.

COMPLICATIONS:
1.COUVELAIRE UTERUS OR UTERINE APOPLEXY INFILTRATION OF BLOOD INTO THE UTERINE MUSCULATURE RESULTING IN THE UTERUS BECOMING HARD & COPPER COLORED. 2. HEMORRHAGE & SHOCK TREATED BY BLOOD TRANSFUSION 3. DIC MANAGED BY FIBRINOGEN & CRYOPRECIPITATE

Disorder of blood clotting = fibrinogen levels fall below effective limits ( hypofibrinogenemia) This problem begins with the excessive triggering of coagulation mechanisms, most commonly encountered in abruptio placenta, PIH, amniotic fluid embolism. This overstimulation of the coagulation system leads to rapid formation of massive numbers of clots. In turn, the fibrinolytic system is overactivated & clots are broken down. As a result, clotting factors are used up & generalized hemorrhage occurs leading to shock & death.

Symptoms Bruising or bleeding massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrinolytic activity, resulting in decreased platelet and fibrinogen levels signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc) monitor PT, PTT, and Hct, protect from injury; no IM injections

Tx:Replacement of clotting factors _ Cryoprecipitate or fresh frozen plasma or platelet transfusion

HYPERTENSIVE DISORDERS IN PREGNANCY:

GESTATIONAL HYPERTENSION: - HYPERTENSION THAT DEVELOPS DURING PREGNANCY OR DURING THE FIRST 24 HOURS AFTER DELIVERY WHICH IS NOT ACCOMPANIED BY EDEMA, PROTEINURIA & CONVULSIONS & DISAPPEARS WITHIN 10 DAYS AFTER DELIVERY.

CHRONIC HYPERTENSION:
- THE PRESENCE OF HYPERTENSION BEFORE PREGNANCY OR HYPERTENSION THAT DEVELOP BEFORE 20 WEEKS GESTATION IN THE ABSENCE OF H-MOLE & PERSIST BEYOND THE POSTPARTUM PERIOD. PREGNANCY INDUCED HYPERTENSION (TOXEMIA): - HYPERTENSION THAT DEVELOPS AFTER THE 20TH WEEK OF GESTATION TO A PREVIOUSLY NORMOTENSIVE WOMAN.

RISK FACTORS:
1. SAID TO BE A DISEASE OF PRIMIPARAS HIGHER INCIDENCE IN PRIMIPARAS BELOW 17 & ABOVE 35 YEARS. 2. LOW SOCIO ECONOMIC STATUS ( LOW PROTEIN INTAKE )
3. HISTORY OF CHRONIC HYPERTENSION ON THE MOTHER, H-MOLE, DIABETES MELLITUS,MULTIPLE PREGNANCY, POLYHYDRAMNIOS, RENAL DISEASE, HEART DISEASE 4. HEREDITARY hx of preeclampsia in mothers or sisters 5. H-mole 6. Previous hx of preeclampsia

CAUSES: 1. UNKNOWN 2. PROTEIN DEFICIENCY THEORY 3. UTERINE ISCHEMIA 4. ARTERIAL VASOSPASM

TRIAD SX:
I HYPERTENSION 2. EDEMA ( INCRESE IN WEIGHT)

3. PROTEINURIA
= 2nd leading cause of maternal death = chief causes of maternal death due to PIH: - cerebral hemorrhage - cardiac failure with pulmonary edema

- renal, hepatic or resp. failure

- obstetric hemorrhage assoc. with abruptio

placenta

VASOSPASM due to damage to the endothelium

VASCULAR EFFECTS
VASOCONSTRICTION

KIDNEY EFFECTS
DECREASED GLOMERULI FILTRATION RATE & INCREASED PERMEABILITY OF GLOMERULI MEMBRANES

INTERSTITIAL EFFECTS
DIFFUSION OF FLUID FROM BLOOD STREAM INTO INTERSTITIAL TISSUE

POOR ORGAN PERFUSION INCREASED BP

Inc BLOOD UREA NITROGEN, URIC ACID, CREATININE DECREASED URINE OUTPUT & PROTEINURIA

EDEMA

Warning Signs:
Rapid weight gain, 4-5 lbs in a single week Sudden swelling Swelling of face & hands Swelling of ankles or feet that does not go away after 12 hours rest A rise in BP Protein in the urine Severe headaches Blurry vision Seeing spots in the eyes Severe pain over the stomach, under the ribs Decrease in the amount of urine

S & SX BLOOD PRESSURE

MILD PREECLAMPSIA

SEVERE PREECLAMPSIA

140/90; Systolic 160/110 elevation of 30 mm/Hg Diastolic elevation of 15 mm/Hg +1 to +2 +3 to +4 in clean catch 300 mg/ L24 hour urine urine or 5 g/24 hour urine collection collection Digital edema ( +1 +2) Dependent edema 3 lb/week Not less than 500 ml/24 hours Occasional headache Normal to +1 +2 Absent Pitting edema (+3 +4) Generalized edema More rapid weight gain Less than 500 ml/24 hours; oliguria Severe headache Hyperreflexia,+3 +4 Photophobia, blurring spots before the eyes

Proteinuria

Edema

Weight Gain Urinary Output Headache Reflexes Visual Disturbances

Epigastric Pain (liver involvement)

Absent

Right upper quadrant pain (aura to convulsion)

EDEMA: (+1) PHYSIOLOGIC TYPE IN PREGNANCY, THERE IS SLIGHT EDEMA IN THE LOWER EXTREMITIES ( DUE TO PRESSURE & POSTURE) (+2) MARKED EDEMA OF LOWER EXREMITIES (PATHOLOGIC) (+3) EDEMA FOUND ON THE FACE & FINGERS. (+4) GENERALIZED EDEMA ( ANASARCA)

SEIZURE PRECAUTIONS: 1. SIDE RAILS UP 2.PAD THE SIDE RAILS 3. PUT BED AT LOWEST POSITION. 4. ROOM SHOULD BE DIM, QUIET,& AWAY FROM AREAS OF ACTIVITY. ( AVOID BRIGHT LIGHTS SUCH AS FLASHLIGHTS) 5. RESTRICT VISITORS TO ALLOW PATIENT TO REST.

6. HAVE EMERGENCY EQUIPMENT AVAILBLE:

- SUCTION APPARATUS, MAGNESIUM SULFATE, CALCIUM GLUCONATE, O2 MEDICATIONS: 1.HYDRALAZINE ( APRESOLINE )

- ANTIHYPERTENSIVE ( PERIPHERAL VASODILATOR) USED TO DECREASE Hpn

Dosage 5-10 mg/IV - administer slowly to avoid sudden fall in BP - Maintain diastolic pressure at 90 mm/Hg to ensure adequate placental filling

2. MAGNESIUM SULFATE ( MgSO4)

- DRUG OF CHOICE TO TREAT & PREVENT CONVULSIONS, also a muscle relaxant - Loading dose is 4-6g. Maintenance dose is 12g/h IV - Infuse loading dose slowly over 15-30 min. - Always administer as a piggyback infusion - Serum Mg level should remain below 7.5 mEq/L

ACTIONS OF MgSO4:
a. PREVENT CONVULSION b. REDUCE BLOOD PRESSURE CHECK THE FOLLOWING FIRST BEFORE ADMINISTERING MgSO4: 1. DEEP TENDON REFLEX PRESENT - +2 ( NORMAL) 2. RR SHOULD BE AT LEAST 12 BPM 3. URINE OUTPUT SHOULD BE AT LEAST 30 ML/HR

** IF MgSO4 TOXICITY DEVELOPS AS SHOWN BY RR DEPRESSION TO LESS THAN 12 BPM & DISAPPEARANCE OF THE DTR, GIVE THE ANTIDOTE CALCIUM GLUCONATE & NOTIFY PHYSICIAN.
- 1g/IV ( 10 ml of a 10% sol) - have prepared at bedside when administering MgSO4 ** IF MgSO4 IS GIVEN POSTPARTUM, MONITOR FOR UTERINE ATONY AS IT CAN CAUSE UTERINE RELAXATION.

Repeat doses should not be given & physician should be notified if any of the following signs of Mg toxicity exist: Patellar knee jerk absent ( test brachial reflexes if epidural anesthesia is present) Respirations less than 12/min Urine output less than 30 ml/hr Signs of fetal distress Elevated serum Mg levels ( more than 8 mg/dl)

Diazepam ( Valium)

Halt seizures 5-10 mg/IV Administer slowly Dose may be repeated every 5-10 mins ( up to 30 mg/hr) Observe for respiratory depression or hypotension in mother & respiratory depression & hypotonia in infant at birth.

MANAGEMENT:

A. AMBULATORY MX
1. HOME MANAGEMENT IS ALLOWED ONLY IF: a. BP IS 140/90 O BELOW b. THERE IS NO PROTEINURIA c. THERE IS NO FETAL GROWTH RETARDATION d. THE PATIENT IS NOT A YOUNG PRIMIPARA. 2. BED REST THE WOMAN SHOULD BE IN BED REST FOR MOST PART OF THE DAY & FREE FROM PHYSICAL & EMOTIONAL STRESS.

3. THE WOMAN SHOULD CONSULT THE CLINIC AS OFTEN AS NECESSARY. 4. DIET SHOULD BE HIGH IN PROTEIN & CARBOHYDRATES WITH MODERATE SODIUM RESTRICTION. 5. HOSPITALIZATION IS NECESSARY IF CONDITION WORSENS.

6. PROVIDE DETAILED INSTRUCTIONS ABOUT WARNING SIGNS:

a. EPIGASTRIC PAIN AURA TO CONVULSION b. VISUAL DISTURBANCES c. SEVERE CONTINUOUS HEADACHE

d. NAUSEA & VOMITING

B. HOSPITAL MANAGEMENT: 1. BP GOES ABOVE 140/90 mm Hg 2. BED REST IS ONE OF THE MOST IMPORTANT PRINCIPLES OF CARE. a. REST IN LEFT LATERAL POSITION TO PROMOTE BLOOD SUPPLY TO THE PLACENTA & THE FETUS.

STAGES OF CONVULSION: 1. STAGE OF INVASION FACIAL TWITCHING, ROLLING OF THE EYES TO ONE SIDE, STARING FIXEDLY IN SPACE. 2. TONIC PHASE BODY BECOMES RIGID, AS ALL MUSCLES GO INTO VIOLENT SPASMS OR CONTRACTIONS, EYES PROTRUDE, HANDS ARE CLENCHED, WOMAN STOPS BREATHING FOR 1520 SECONDS. 3. CLONIC PHASE JAWS & EYELIDS CLOSE & OPEN VIOLENTLY, FOAMING OF THE MOUTH, FACE BECOMES CONGESTED & PURPLE,MUSCLES OF THE BODY CONTRACT & RELAX ALTERNATELY.

THE CONTRACTIONS ARE SO VIOLENT THAT THE WOMAN MAY THROW HERSELF OUT OF BED. LASTS FOR ABOUT A FEW MINUTES. 4. POST ICTAL PHASE WOMAN IS SEMICOMATOSE, NO MORE VIOLENT MUSCULAR CONTRACTIONS. THE PATIENT WILL NOT REMEMBER THE CONVULSION & THE EVENTS IMMEDIATELY BEFORE & AFTER.

RESPONSIBILITIES DURING A CONVULSION

1. ALWAYS MONITOR PATIENT FOR IMPENDING SIGNS OF CONVULSION: EPIGASTRIC PAIN, SEVERE HEADACHE, NAUSEA & VOMITING. 2 THE MAIN RESPONSIBILITIES OF A NURSE DURING A CONVULSION ARE: MAINTENANCE PF PATENT AIRWAY & PROTECTION OF PATIENT FROM INJURY. 3. TURN PATIENT TO HER SIDE TO ALLOW DRAINAGE OF SALIVA & PREVENT ASPIRATION. 4. NEVER LEAVE AN ECLAMPTIC PATIENT ALONE

5. DO NOT RESTRICT MOVEMENT DURING A CONVULSION AS THIS COULD RESULT IN FRACTURES. 6. WATCH FOR SIGNS OF ABRUPTIO PLACENTA: VAGINAL BLEEDING, ABDOMINAL PAIN, DECREASED FETAL ACTIVITY. 7. TAKE VITAL SIGNS & FHT AFTER A CONVULSION. 8. DO NOT GIVE ANYTHING BY MOUTH UNLESS THE WOMAN IS FULLY AWAKE AFTER A CONVULSION

** THE ONLY KNOWN CURE OF PIH IS DELIVERY OF THE BABY.

** AS SOON AS THE BABY IS STABLE, THE BABY IS DELIVERED. ** THE PREFERRED METHOD OF DELIVERY IS VAGINAL .

** IF LABOR INDUCTION IS UNSUCCESSFUL & FETAL DISTRESS IS SO SEVERE THAT THE FETUS NEED TO BE DELIVERED, CESARIAN SECTION IS PERFORMED.

POSTPARTUM CARE:
1. THE DANGER OF CONVULSION EXISTS UNTIL 24 HOURS AFTER DELIVERY. MgSO4 THERAPY IS CONTINUED UNTIL THE IMMEDIATE 24 HOUR POSTPARTUM. 2. ERGOT PRODUCTS ARE CONTRAINDICATED BECAUSE THEY ARE HYPERTENSIVES. 3. TWO YEARS SHOULD ELAPSE BEFORE ANOTHER PREGNANCY IS ATTEMPTED TO DECREASE THE LIKELIHOOD THAT PIH WILL RECUR ON THE SUBSEQUENT PREGNANCY.

H hemolysis EL elevated liver enzymes LP low platelets Severe case of PIH Cause is unknown Occurs in both primis and multis

S/S: nausea, epigastric pain, general malaise, right upper quadrant tenderness Laboratory results: hemolysis of RBC ( fragmented on a peripheral blood smear), thrombocytopenia ( platelet count below 100,000/mm3) & elevated liver enzymes ( ALT) alanine amino transferase ( AST) serum aspartate aminotransferase liver enzymes are elevated from hemorrhage and liver necrosis.

Mx: Transfusion of fresh frozen plasma Cx: liver hematoma, hyponatremia, renal failure, hypoglycemia. Method of delivery preferred: vaginal or CS ** Maternal bleeding may occur at birth because of poor clotting ability. Epidural anesthesia may not be possible because of the low platelet count and the high possibility of bleeding at the epidural site

Is labor that occurs between 20 weeks to 37 weeks gestation characterized by regular uterine contraction ( four every 20 minutes) that lasts more than 30 seconds & result in cervical dilatation & effacement. It is the greatest cause of neonatal mortality & morbidity.

Causes: PROM most often associated with infection Retained IUD Fetal death History of premature labor & abortion Overdistention of the uterus caused by multiple pregnancy, hydramnios Incompetent cervix Dehydration UTI Chorioamnionitis infection of the fetal membranes and fluid

SSx: Persistent, dull, ;low backache, Dx is made when there is regular uterine contractions occuring 5-8 minutes apart accompanied by:

Progressive cervical changes Cervical dilatation of more than 2 cm Cervical effacement of 80% or more Duration of at least 30 secs 10 mins apart

Menstrual like cramping Watery or bloody vaginal discharge Low back pain

MX:
1. Prevention regular prenatal check up 2. If fetus is less than 32-34 weeks, and still premature to be delivered, labor must be arrested: 1. Bedrest on LLP to promote blood flow to the placenta 2. Hydration IV fluids

3. Tocolytics medications to stop uterine contractions ( relaxes smooth muscles)

1. Ritodrine Hcl

2. Terbutaline ( check pulse rate because it can cause tachycardia)

Drugs to hasten fetal lung maturity:

- GLUCOCORTICOID therapy if labor can be delayed for 48 hours administration of BETAMETHASONE accelerate fetal lung maturity & prevents respiratory distress & hyaline membrane disease ( most common problem of the premature neonate). -

Is a corticosteroid that acts as antiinflammatory & immunosuppressive agent. It is given to pregnant women 12 to 24 hrs before birth to hasten fetal lung maturity if the fetus is less than 34 weeks gestation & help prevent RDS in the newborn Dosage: 12-12.5 mg IM initially; maybe repeated in 24 hrs & again in 1 to 2 weeks Adverse effects: burning, itching, irritation at the injection site, swelling, tachycardia, headache,

When 2 ( twin), 3 ( triplets), 4 ( quadruplets) or even 5(quintuplets) fetuses develop in the uterus at the same time. A multifetal pregnancy is associated with more risks than a singleton pregnancy

Twins 2 fetuses Triplets 3 fetuses Quadruplets 4 fetuses Quintuplets 5 fetuses

TYPES: MONOZYGOTIC or IDENTICAL TWIN

Develop from one ovum & one sperm cell that undergo rapid cell division after fertilization that resulted in two or more individuals. Since they come from only one sperm and one ovum, these individuals possess the same genetic traits and are always of the same sex.

If twinning occurred within 72 hours after fertilization, there will be:

2 amnions ( diamnionic) 2 chorions ( dichorionic) 2 embryos

If twinning occurred between the 4th & 8th day after fertilization, there will be :
2 amnions 1 chorion ( monochorionic) 2 embryos

If twinning occurred after 8 days, there will be :

1 amnion ( monoamnionic) 1 chorion 2 embryos

If twinning occurred after the embryonic disc is formed, CONJOINED TWINS will develop. Conjoined twins are classified according to the part of the body where they are attached.
Anterior Thoracopagus Posterior pyopagus Cephalic craniopagus Caudal Ischiopagus

DIZYGOTIC TWINS or FRATERNAL TWINS

Develop from 2 or more ova and sperm cells that were fertilized at the same time. They have different genetic traits, may or may not be of the same sex and always have 2 chorions & 2 amnions. ** More females than males because female zygote has a higher tendency to divide into twins ** Female zygotes have higher rate of survival than male zygotes

Predisposing factors of Dizygotic Twinning

Race highest in black women Heredity more common in women with familial history of twinning Age & parity increased incidence in high parity & advanced maternal age Higher incidence in women taking fertility drugs that promote ovulation & release of several ova at the same time Higher incidence within the first months after stopping oral contraceptives because of the sudden & greater amount of pituitary gonadotropin released at this time In vitro fertilization stimulation of formation of numerous follicles, harvesting them in the ovary & fertilizing them in vitro. All zygotes that were fertilized are returned to the uterus to grow & develop

Complications of Multiple Fetuses:

Abortion Death of one fetus Perinatal mortality Preterm labor as the number of fetuses increases, the duration of pregnancy decreases Low birth weight Congenital malformations Hydramnios Maternal hypertension Placenta previa & Abruptio placenta Intrauterine growth retardation Cord entanglement, prolapse & compression Maternal anemia

S/Sx

1. Uterus large for gestational age 2. Auscultation of two or more fetal heart tone 3. Hx of twins in the family 4. Palpation of three or more large fetal parts 5.Ultrasound reveals two or more gestational sac

Clinic Visit: First Trimester every month Second Trimester every 2 weeks Third Trimester every week Nutrition additional 300 kcal to the normal pregnancy requirement 6 small meals rather than 3 large meals to decrease discomfort of a large uterus compressing a full stomach

Labor and Delivery: The cord is cut right after delivery of the first infant Presentation of second infant is ascertained after birth of first twin either by ultrasound or Leopolds or both The normal interval of delivery of the first twin and second twin is (30 minutes) If the second twin cannot be delivered vaginally because of abnormal position, CS is done.

Cesarean delivery delivery of choice if the twins or one of them cannot be delivered normally or if complications arise that necessitate immediate delivery. Post partum period watch out for Hemorrhage due to overdistention of the uterus.

HEART DISEASE CLASSIFICATION: 1. CLASS I = NO LIMITATION,UNCOMPROMISED

= ASYMPTOMATIC, NO DISCOMFORT WITH ORDINARY PHYSICAL ACTIVITY. 2. CLASS II =SLIGHT LIMITATION, SLIGHTLY COMPROMISED, ORDINARY ACTIVITY CAUSES DYSPNEA, FATIGUE, CHEST PAIN & PALPITATIONS.

3. CLASS III = MARKED LIMITATION LESS THAN ORDINARY ACTIVITY CAUSE EXCESSIVE FATIGUE; PALPITATIONS, CHEST PAIN & DYSPNEA.
4. CLASS IV =SEVERE LIMITATION; PATIENT EXPERIENCES SYMPTOMS EVEN AT REST; UNABLE TO PERFORM ANY PHYSICAL ACTIVITY WITHOUT DISCOMFORT.

NURSE ALERT:

** REMEMBER A PREGNANT WOMAN WITH HEART DISEASE SHOULD AVOID INFECTION, EXCESSIVE WEIGHT GAIN, EDEMA & ANEMIA BECAUSE THESE CONDITIONS INCREASE THE WORKLOAD OF THE HEART.

MX:
A.PRENATAL CARE: 1. PROMOTION OF REST ( CLASS I & CLASS II) * 8 HOURS OF SLEEP DURING THE NIGHT & HAVE FREQUENT REST PERIODS DURING THE DAY. * LIGHT WORK IS ALLOWED BUT NO HEAVY WORK, NO STAIR CLIMBING, NO EXHAUSTION.

2. DIET
* HIGH IN IRON, PROTEIN,MINERALS & VITAMINS

3. AVOID HIGH ALTITUDES, SMOKING AREAS, UNPRESSURIZED PLANES & OVERCROWDED AREAS. CIGARETTE SMOKING & ALCOHOLIC BEVERAGES ARE STRICTLY PROHIBITED.

4.PREVENTION OF INFECTION
* AVOID PERSONS WITH ACTIVE INFECTIONS (COLDS, COUGH). * EARLY TREATMENT OF INFECTIONS 5. PROVIDE INSTRUCTIONS ON DANGER SIGNS OF HEART FAILURE: * COUGH WITH CRACKLES IS USUALLY THE FIRST SIGN OF AN IMPENDING HEART FAILURE.

* INCREASING DYSPNEA, TACHYCARDIA, RALES, EDEMA MEDICATIONS:

>IRON SUPPLEMENTATION TO PREVENT ANEMIA >DIGITALIS TO STRENGTHEN MYOCARDIAL CONTRACTION AND SLOW DOWN HEART RATE >NITROGLYCERINE TO RELIEVE CHEST PAIN >ANTIBIOTICS TO PREVENT AND TREAT INFECTION >DIURETICS MAY BE PRESCRIBED IN CASE OF HEART FAILURE

INTRAPARTAL CARE

1.EARLY HOSPITALIZATION- WOMAN IS HOSPITALIZED BEFORE LABOR BEGINS TO PROMOTE REST, FOR CLOSER SUPERVISION AND PREVENT INFECTION 2.WOMAN LABORS IN SEMI-FOWLERS POSITION OR LEFT LATERAL RECUMBENT POSITION. NO LITHOMY POSITION. 3.VITAL SIGNS- VITAL SIGNS ARE MONITORED CONTINUOUSLY. TACHYCARDIA AND RESPIRATORY RATE MORE THAN 24 ARE SIGNS OF IMPENDING CARDIAC DECOMPENSATION. DURING THE FIRST STAGE, MONITOR VITAL SIGNS EVERY 15 MINUTES AND MORE FREQUENTLY DURING THE SECOND STAGE

4.EPIDURAL ANESTHESIA- IS INSTITUTED FOR PAINLESS AND PUSHLESS DELIVERY. FORCEPS IS USED TO SHORTEN THE SECOND STAGE. PUSHING IS CONTRAINDICATED 5. WOMEN WITH HEART DISEASE ARE POOR CANDIDATE FOR CS DUE TO INCREASED RISK FOR HEMORRHAGE, *INFECTION AND THROMBOEMBOLISM
POSTPARTUM CARE 1. THE MOST DANGEROUS PERIOD IS THE IMMEDIATE POSTPARTUM BECAUSE OF THE SUDDEN INCREASE IN CIRCULATORY BLOOD VOLUME.

2. MONITOR VITAL SIGNS.

3. PROMOTE REST- RESTRICT VISITORS TO ALLOW PATIENT TO REST, THE WOMAN STAYS IN THE HOSPITAL LONGER, UNTIL CARDIAC STATUS HAS STABILIZED. 4. EARLY BUT GRADUAL AMBULATION TO PREVENT THROMBOPHLEBITIS. 5. MEDICATIONS *ANTIBIOTICS *STOOL SOFTENERS TO PREVENT STRAINING AT STOOL CAUSED BY CONSTIPATION. SEDATIVES MAY BE ORDERED TO PROMOTE REST.

6. BREASTFEEDING IS ALLOWED IF THERE ARE NO SIGNS OF CARDIAC DECOMPENSATION DURING PREGNANCY, LABOR AND PUEPERIUM.

Hemolytic Disease:
ISOIMMUNIZATION / RH INCOMPATIBILITY - OCCURS WHEN AN RH-NEGATIVE MOTHER IS CARRYING AN RH-POSITIVE FETUS. - FOR SUCH A SITUATION TO OCCUR, THE FATHER OF THE CHILD MUST EITHER BE A HOMOZYGOUS ( DD) OR HETEROZYGOUS ( Dd) RH POSITIVE. - IF THE FATHER OF THE CHILD IS HOMOZYGOUS (DD), 100% OF THE COUPLES CHILDREN WILL BE RH (+).

-PEOPLE WHO HAVE RH (+) BLOOD HAVE A PROTEIN FACTOR ( D ANTIGEN) THAT RH (-) PEOPLE DO NOT. - WHEN AN RH(+) FETUS BEGINS TO GROW INSIDE AN RH (-) MOTHER, IT IS THOUGH HER BODY IS BEING INVADED BY FOREIGN AGENT, OR ANTIGEN. - THEORETICALLY, THERE IS NO CONNECTION BETWEEN FETAL BLOOD & MATERNAL BLOOD DURING PREGNANCY BUT

BUT SOMETIMES ACCIDENTAL BREAKS IN THE PLACENTAL VILLI RESULTS IN FETAL BLOOD ENTERING THE MATERNAL BLOODSTREAM. (ex: AMNIOCENTESIS , PUBS, ABORTION).
- ONLY A FEW ANTIBODIES ARE FORMED THIS WAY SO THAT IT DOES NOT AFFECT THE FIRST INFANT. - DURING PLACENTAL SEPARATION AND DELIVERY, A GREAT AMOUNT OF MATERNAL & FETAL BLOOD ARE MIXED, CAUSING THE MOTHER TO PRODUCE LARGE AMOUNTS OF ANTIBODIES DURING THE FIRST 72 HOURS AFTER PLACENTAL DELIVERY.

- IF THE FETUS IN SUBSEQUENT PREGNANCIES IS RH (+), THE ANTIBODIES ALREADY PRESENT IN THE BLOODSTREAM WILL CROSS THE PLACENTA, ATTACK & DESTROY THE FETAL RED BLOOD CELLS ( HEMOLYSIS). THE FETUS BECOMES SO DEFICIENT IN RBCS THAT SUFFICIENT O2 TRANSPORT TO BODY CELLS CANNOT BE MAINTAINED. THIS CONDITION IS TERMED HEMOLYTIC DISEASE OF THE NEWBORN OR ERYTHROBLASTOSIS FETALIS.

DX:
1. INDIRECT COOMBS TEST TEST TO CHECK FOR THE PRESENCE OF ANTIBODIES IN MATERNAL SERUM. 2. DIRECT COOMBS TEST TEST TO CHECK THE PRESENCE OF ANTIBODIES IN FETAL CORD BLOOD.

Administration of Rh ( anti D) globulin (Rhogam) at 28 weeks gestation and within the first 72 hours after delivery to a woman who:
Have delivered Rh positive fetus Have had untypeable pregnancies such as ectopic pregnancies, stillbirth & abortion Have received ABO compatible Rh positive blood Have had invasive diagnostic procedure such as amniocentesis, PUBS ( cordocentesis)

ABO INCOMPATIBILITY The problem occurs when the maternal blood enters fetal circulation. Most common: mother is Type O and the fetus is either Type A, B, or AB The mothers plasma naturally contains anti-A and anti B antibodies With weaker hemolytic effect than Rh antibodies and only affect mature RBCs Number of antibodies is limited to the amount of maternal blood that entered circulation May affect fetus of the 1st pregnancy Affected newborn will become jaundiced in the first 3 days of life

Possible combinations for ABO INCOMPATIBILITY MOTHER A B O FETUS

B A A, B, AB

MX of HEMOLYTIC DISEASE:

1. SUSPENSION OF BREASTFEEDING DURING THE FIRST 24 HOURS TO PREVENT PREGNANEDIOL (BREAKDOWN PRODUCT OF PROGESTERONE EXCRETED IN BREASTMILK) FROM INTERFERING WITH THE CONJUGATION OF INDIRECT BILIRUBIN TO DIRECT BILIRUBIN.
2. PHOTOTHERAPY DESTRUCTION OF RBCS RESULTS IN THE FORMATION OF INDIRECT BILIRUBIN. INDIRECT BILIRUBIN MUST FIRST BE CONVERTED TO DIRECT BILIRUBIN BY THE LIVER CELLS BEFORE IT CAN BE EXCRETED IN THE BODY. THE LIVER IS IMMATURE AT BIRTH SO IT CANNOT CONVERT LARGE AMOUNTS OF

BILIRUBIN FORMED DURING HEMOLYSIS OF RBC.

a. USES BILI OR FLUORESCENT LIGHTS POSITIONED 18 20 INCHES ( 12-30) ABOVE THE INFANT. NURSING CARE DURING PHOTOTHERAPY: 1. COVER EYES WITH DRESSING 2. COVER GENITALS TO PREVENT PRIAPISM. 3. EXPECT THE STOOL TO BE LOOSE & BRIGHT GREEN FROM EXCESSIVE BILIRUBIN EXCRETION & THE SKIN TO BE DARK BROWN ( BRONZE BABY SYNDROME).

4. PROVIDE GOOD SKIN CARE BECAUSE STOOL CAN BE IRRITATING TO THE SKIN. 5. EXPECT THE URINE TO BE DARK COLORED BECAUSE OF UROBILINOGEN FORMATION. 6. ASSESS FOR DEHYDRATION ( I & O ; SKIN TURGOR). FLUID LOSS THROUGH INSENSIBLE WATER LOSS MAY OCCUR BECAUSE OF THE HEAT FROM THE FLUORESCENT LIGHT ABOVE THE INFANT. 7. OFFER GLUCOSE WATER EVERY 3 HOURS TO PREVENT DEHYDRATION. 8. MAINTAIN BODY TEMP BETWEEN 36C & 37C.

EXCHANGE TRANSFUSION:
1. INTRAUTERINE TRANSFUSION: - DONE BY INJECTING RBCS DIRECTLY INTO A VESSEL IN THE FETAL CORD OR DEPOSITING THEM IN THE FETAL ABDOMEN USING AMNIOCENTESIS TECHNIQUE.

- BLOOD USED FOR TRANSFUSION IS EITHER THE FETUS OWN TYPE OR GROUP O NEGATVE IF THE FETAL BLOOD TYPE IS UNKNOWN. -FROM 75 TO 150 ML OF WASHED RBCS WILL BE USED, DEPENDING ON THE AGE OF THE FETUS.

NOTE:
ADMINISTER RhoGAM TO ALL Rh (-) MOTHERS DURING PREGNANCY ( AT 28 WEEKS GESTATION) AND WITHIN 72 HOURS OF DELIVERY OR ABORTION OF AN Rh (+) FETUS **

- AFTER BIRTH, THE INFANT MAY REQUIRE AN EXCHANGE TRANSFUSION TO REMOVE HEMOLYZED BLOOD CELLS & REPLACE THEM WITH HEALTHY ONES.
Notify your healthcare provider if your baby has any of the following s/s after returning home:

> Fever
> Jaundice > Poor appetite or poor weight gain > Excessive crying that does not stop when the baby is held.

Signs in the newborn: Paleness Jaundice that begins within 24 hours after delivery ( pathologic jaundice) Unexplained bruising or blood spots under the skin Tissue swelling ( edema) Seizures Lack of normal movement Poor reflex response

Gestational Diabetes Mellitus

-is a hereditary endocrine disorder due to inadequate or lack of insulin production that results in impaired glucose absorption & metabolism. - all women appear to develop an insulin resistance as pregnancy progresses ( insulin does not seem normally effective during pregnancy) a phenomenon that is probably caused by the presence of the hormone Human Placental Lactogen (HPL)

SSx: 1. Hyperglycemia pancreas does not produce enough insulin , thus glucose is unable to enter the cells & accumulates in the bloodstream resulting in hyperglycemia

2. Glycosuria when blood glucose levels goes beyond the renal threshold for sugar, glucose spills on the urine.
3. Polyuria glucose attracts water so that when it is excreted in the kidney, it brings along with it large amounts of water resulting in the woman excreting large amounts of urine, a condition called, POLYURIA. 4. Polydipsia the excretion of large amounts of fluid from the body leads to dehydration. Excessive thirst or polydipsia is an important symptom of dehydration.

Effects of Diabetes:

Mother:
1. Increased tendency to pre-eclampsia & eclampsia, UTI, & candidiasis 2. Increased risk for postpartum hemorrhage d/t overdistention of the uterus. 3. Maternal mortality 4. Preterm delivery

Infant:
1. Macrosomia 2. Hydramnios 3. Prematurity 4. Hypoglycemia ( lowered serum glucose levels)

5. Predisposition to diabetes mellitus later in life as the disease is hereditary

Complications:
1. Macrosomia Infants of women with poorly controlled diabetes tend to be large ( more than 10 lbs) because glucose can cross the placental barrier, it acts acts as a growth stimulant. The increased glucose adds subcutaneous fat deposits. All the nutrients that the fetus receives comes directly from the mothers blood. 2. Birth Injury may occur due to the babys large size and difficulty being born.( may cause CPD which may necessitate being born by CS)

3. HYPOGLYCEMIA refers to low blood sugar in the baby immediately after delivery. This problem occurs if the mothers blood sugar levels have been consistently high, causing the fetus to have a high level of insulin in its circulation. After delivery, the baby continues to have a high insulin level, but no longer has the high level of sugar from its mother, resulting in the newborns blood sugar level becoming very low. The babys blood sugar level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously

4. Respiratory distress (difficulty breathing) too much insulin or too much glucose in a babys system may delay lung maturation and cause respiratory difficulties in babies. This is more likely if they are born before 37 weeks of pregnancy.

Prenatal Management: 1. Diagnosis; Suspect DM in a woman

a. b. c. d.

e.

With family history of DM With history of unexplained repeated abortions and stillbirth With glycosuria Who are obese Who have history of giving birth to large infants, over 10 lbs. and infants with congenital anomaly

2. Screening tests
a.

Universal screening- 50 gram oral glucose tolerance test ( OGTT) between 24-28 weeks gestation irregardless of the time of the day and meals taken for all pregnant women. If the plasma value is more than 140 mg/dl after one hour, 100 gram three hour oral glucose tolerance test is performed to confirm if the woman is having hypergycemia.

Criteria of 100 gram Oral Glucose Tolerance Test(Instruct not to eat after midnight) Time of Test Venous Level Plasma Level

Fasting
1-hour 2-hour 3-hour

90mg/dl
165mg/dl 145mg/dl 125mg/dl

105mg/dl
190mg/dl 165mg/dl 145mg/dl

3.

Diet
a.

b.

c.

Caloric intake should be enough to meet needs of pregnancy, fetus and mother (1,800 to 2,400 cal/day) but not too much to promote excessive weigh gain. 20% of caloric intake should come from protein foods, 50% from carbohydrates, 30% from fats. Weight gain should be about 24 lbs. Too much weight gain can lead to large infants and cephalopevic disproportion. Teach and instruct to:

Reduce saturated fat Reduce cholesterol Increase dietary fiber Avoid fasting and feasting

d.

e.

Have the woman become familiar with food exchange list and caloric values of foods she usually eats to enable her to plan her diet properly and estimate her caloric intake accurately. The goal is to maintain a fasting blood sugar level of 80 mg/dl and postprandial blood sugar level of 110mg/dl

4.

Exercise

A liberal cardiovascular-conditioning exercise and diet therapy is the management for Gestational Diabetes Mellitus Exercise lowers blood glucose levels and decreases the need for insulin. The exercise regimen should be individualized, performed regularly and under supervision. Advise woman to eat complex carbohydrates before exercising to prevent hypoglycemia.

Remember that hypoglycemia could occur in persons undergoing insulin therapy during peak action hour of insulin:

Short acting or regular insulin after 2-3 hours of injection Intermediate or Lente insulin after 6-8 hours of injection Long-acting or ultralente after 16 18 hours of injection The sign of hypoglycemia are: dizziness, diaphoresis, weakness, blurring of vision Give a hypoglycemic person a glass of orange juice.

5.

Insulin therapy

Insulin requirements increase during pregnancy Oral hypoglycemics such as Tolbutamide and Diamicron are contraindicated during pregnancy because they are teratogenic for they can cross the placenta and may cause fetal and new born hypoglycemia. Combined fast acting and intermediate insulin made up of human derivative/humulin. Humulin is the insulin of choice during pregnancy because it is the least allergenic 2/3 in the morning, 1/3 at dinner administered subcutaneously hour before meals. Insulin requirement is decreased on the first trimester due to nausea & vomiting and highest during the third trimester.

Delivery:
1.

2. 3.

Delivery is effected when the fetus is mature enough after 38 weeks gestation, but not too large so as to cause cephalopelvic disproportion. Thus, early hospitalization and labor induction is performed to deliver the baby before it becomes too large to pass the birth canal If cervix is not yet ripe, baby is macrosomic and fetal distress occurs, CS is performed Regular insulin is given on the day of delivery not long acting insulin because insulin requirement drop immediately after delivery. The woman may not require insulin during the first 24 hours postpartum and her insulin requirements usually fluctuates during the next few days.

4. Contraception:
a.

a.

IUD and combined oral contraceptives are contraindicated *Progesterone interferes with insulin activity therefore increases blood glucose levels. *Estrogen increases lipid & cholesterol levels & risk for increased blood coagulation Norplant (subcutaneous progestin implant system) or Depo -provera may be good choices & safely used by diabetic women

Timing of administration 1. Before 5 cm (latent phase) may retard or stop labor 2. From 5 to 7 cm (early active phase) may aid relaxation

3. After 8 cm (transition phase)

may result in respiratory depression requiring resuscitative measures in sedated neonate

Breathing Techniques During transition phase: Take a deep breath and exhale slowly and completely. At the beginning of a contraction, take a fairly deep breath. Then engage in shallow breathing. If there is an urge to push, puff out every 3rd, 4th, or 5th breath. Take deep breath at the end of contraction.
MLNG CELESTE, RN, MD 73 0

Attitude of woman in labor: As intensity of contractions become stronger & start to cause pain & much discomfort, the woman prefers to stay in bed. She withdraws from her environment as her attention is focused on herself & the sensations on her body.

Nursing Responsibility:
Coach woman on breathing & relaxation techniques. Abdominal breathing is recommended during the latent phase & active phase

Breathing Techniques during labor

Cleansing Breath: Begin and end each breathing technique with a cleansing breath. This is simply a deep quick breath, like a big sigh. Inhalation is through the nose; exhalation is through slightly pursed lips. Slow-Paced Breathing: This technique can be used in early labor and for as long as the mother is comfortable with it. For some women, this may last throughout the entire first stage of labor. 1. Take a cleansing breath as soon the contraction begins. 2. Breathe slowly and deeply in through the nose and out through slightly pursed lips or the nose over the duration of the contraction. 3. Maintain a steady rate of approximately 6 to 9 breaths during a 60-second contraction (the cleansing
MLNG CELESTE, RN, MD

73 2

CESARIAN BIRTH - DELIVERY OF THE BABY THROUGH AN ABDOMINAL & UTERINE INCISION.

INDICATIONS:
1.CEPHALOPELVIC DISPROPORTION(CPD) 2. FETAL DISTRESS 3.BREECH PRESENTATION 4. DYSTOCIA

5. PRIOR CESARIAN SURGERY 6. CORD PROLAPSE 7. ABRUPTIO PLACENTA 8. PLACENTA PREVIA COMPLICATIONS: 1.INFECTIONS 2. HEMORRHAGE 3. BLOOD CLOTS 4. SURGICAL INJURY TO THE BLADDER

OR INTESTINES
5. SURGICAL INJURY TO THE FETUS.

TYPES:

1.LOW SEGMENT / LOW TRANSVERSE / LOW CERVICAL ( LTCS) - INCISION IS MADE TRANSVERSELY ON THE LOWER SEGMENT OF THE UTERUS.( PFANNENSTIEL INCISION)

ADVANTAGES:

1. INVOLVES LESS BLOOD LOSS

2. LESS POSSIBILITY OF RUPTURE OF CS SCAR

DURING SUBSEQUENT PREGNACY 3. LESS INCIDENCE OF POSTOPERATIVE COMPLICATIONS: INFECTION, ADHESION OF BOWEL TO THE INCISIONAL LINE, INTESTINAL OBSTRUCTION. 4. ALLOWS A VAGINAL DELIVERY AFTER A PREVIOUS CESARIAN SECTION.(VBAC)

DISADVANTAGES:

1.DIFFICULT & LONGER TO PERFORM THAN THE CLASSICAL TYPE. 2. NOT RECOMMENDED WITH ANTERIOR PLACENTA PREVIA

2. CLASSICAL TYPE
- A VERTICAL INCISION IS MADE DIRECTLY INTO THE WALLS OF THE CORPUS, WHICH IS THE MOST CONTRACTILE PORTION. ADVANTAGES: 1.EASIEST & QUICKEST INCISION TO PERFORM

2. RAPID EXTRACTION OF FETUS CAN BE DONE.

DISADVANTAGES:

1. INVOLVES MORE BLOOD LOSS BECAUSE

INCISION IS MADE ON THE THICK VASCULAR PORTION OF THE UTERUS 2. HIGHER INCIDENCE OF POST-OP COMPLICATIONS

3. RUPTURE OF CS SCAR ON SUBSEQUENT PREGNANCY IS MORE LIKELY.

4.INVOLVES MORE HEALING DISCOMFORT & A WIDER CS SCAR.

C. THIRD STAGE OF LABOR = STAGE OF PLACENTAL EXPULSION

- BEGINS WITH THE DELIVERY OF THE INFANT TO THE DELIVERY OF THE PLACENTA. SIGNS OF PLACENTAL SEPARATION 1. CALKINS SIGN UTERUS BECOMING ROUND & FIRM & GLOBULAR AGAIN, RISING HIGH TO THE LEVEL OF THE UMBILICUS.

2. SUDDEN GUSH OF BLOOD FROM THE VAGINA 3. LENGTHENING OF THE CORD FROM THE VAGINA TYPES OF PLACENTAL SEPARATION: 1. SCHULTZ IF THE PLACENTA SEPARATES FIRST AT ITS CENTER & LAST AT ITS EDGES, IT TENDS TO FOLD ON ITSELF LIKE AN UMBRELLA & PRESENTS THE FETAL SURFACE WHICH IS SHINY. 80% OF PLACENTAS SEPARATE THIS WAY.

 SHINY FOR SCHULTZ

2. DUNCAN IF THE PLACENTA SEPARATES FIRST AT ITS EDGES, IT SLIDES ALONG THE UTERINE SURFACE & PRESENTS AT THE VAGINA WITH THE MATERNAL SURFACE WHICH IS RAW, RED, & IRREGULAR WITH THE RIDGES OR COTYLEDONS THAT SEPARATE BLOOD COLLECTION SPACES SHOWING. ONLY ABOUT 20% OF PLACENTAS SEPARATE THIS WAY. DIRTY FOR DUNCAN

NURSING CARE: 1. DO NOT HURRY THE EXPULSION OF THE PLACENTA BY FORCEFULLY PULLING OUT THE CORD OR DOING VIGOROUS FUNDAL PUSH AS THIS CAN CAUSE UTERINE INVERSION.

2. TRACT THE CORD SLOWLY, WINDING IT AROUND THE CLAMP UNTIL THE PLACENTA SPONTANEOUSLY COMES OUT ,ROTATING IT SLOWLY SO THAT NO

MEMBRANES ARE LEFT INSIDE THE UTERUS. A METHOD CALLED BRANDT ANDREWS MANEUVER
3. TAKE NOTE OF THE TIME OF PLACENTAL DELIVERY. IT SHOULD BE DELIVERED WITHIN 5 TO 20 MINUTES AFTER THE DELIVERY OF THE BABY, OTHERWISE REFER IMMEDIATELY TO THE PHYSICIAN AS THIS CAN CAUSE SEVERE BLEEDING IN THE MOTHER. ** IF BLEEDING OCCURS & THE PLACENTA CANNOT BE DELIVERED, MANUAL EXTRACTION OF THE PLACENTA IS INDICATED **

4. INSPECT FOR COMPLETENESS OF COTYLEDONS; ANY PLACENTAL FRAGMENT RETAINED CAN ALSO CAUSE SEVERE BLEEDING & POSSIBLE DEATH. ( FIRST NURSING ACTION IN THE 3RD STAGE OF LABOR).

5. PALPATE THE UTERUS TO DETERMINE DEGREE OF CONTRACTION. IF RELAXED, BOGGY OR NON CONTRACTED; THE FIRST NURSING ACTION IS TO MASSAGE GENTLY & PROPERLY. AN ICE CAP OVER THE ABDOMEN WILL ALSO HELP CONTRACT THE UTERUS SINCE COLD CAUSES VASOCONSTRICTION.
6. INJECT OXYTOXICS, METHERGIN OR SYNTOCINON (IM) TO MAINTAIN UTERINE CONTRACTIONS, THUS PREVENTING HEMORRHAGE.

NOTE: OXYTOXICS ARE NOT GIVEN BEFORE PLACENTAL DELIVERY BECAUSE PLACENTAL ENTRAPMENT COULD OCCUR. DO NOT GIVE METHERGIN IF BP IS 130/100 OR ABOVE.
7. INSPECT THE PERINEUM FOR LACERATIONS. ANYTIME THE UTERUS IS FIRM FOLLOWING PLACENTAL DELIVERY, YET BRIGHT RED VAGINAL BLEEDING IS GUSHING FORTH FROM THE VAGINAL OPENING, SUSPECT LACERATIONS.

CATEGORIES OF LACERATIONS
1.FIRST DEGREE INVOLVES THE FOURCHETTE, PERINEAL SKIN VAGINAL MUCUS MEMBRANES 2. SECOND DEGREE INCLUDES THE MUSCLES OF THE PERINEAL BODY. 3. THIRD DEGREE EXTENDS TO THE ANAL SPHINCTER 4. FOURTH DEGREE EXTENDS TO THE MUCOSA OR LUMEN OF THE RECTUM.

D. FOURTH STAGE OF LABOR STAGE OF PUERPERIUM / STAGE OF VIGILANCE

-SAID TO BE THE MOST CRITICAL FOR THE MOTHER BECAUSE OF UNSTABLE VITAL SIGNS.

= STARTS IMMEDIATELY AFTER THE DELIVERY OF THE FETUS UP TO 4 HOURS & IS COMPLETED WHEN THE REPRODUCTIVE TRACT HAS RETURNED TO ITS NON PREGNANT CONDITION

Pelvic Inflammatory Disease: Salphingitis

Inflammatory condition of the pelvic cavity that may involve the ovaries, fallopian tubes, vascular system or pelvic peritoneum. Caused by microorganims colonizing endocervix ascending to endometrium and fallopian tubes Major cause of female infertility Multiple sexual partners Hx of PID Early onset of sexual activity IUD

Risk Factors:

Manifestations:

Pelvic pain ( sharp & cramping); Fever; nausea, malaise; severe lower abdominal pain; Purulent foul smelling vaginal discharge; Menorrhagia; tenderness in both lower abdominal quadrants; dyspareunia

Diagnostics & Laboratory Tests:

Hx & PE; CBC; vaginal & endocervical culture; VDRL; Endometrial biopsy: UTZ;
Antibiotics; IV fluids/ inc. oral fluid; pain meds; Remove IUD; Evaluation of sexual partners; application of heat to relieve pain; surgical excision of abscess if present

Management:

Toxic Shock syndrome ( TSS) Reproductive age, near menses or postpartum period D/t toxins released by S. Aureus R/t use of tampons (Mg absorbing fibers of tampons cause dec Mg levels contributing to toxin production by bacteria in the lower reproductive tract), cervical cap or diaphragm
Manifestations: sudden high fever, headache, vomiting, rash on trunk, desquamation of skin, hypotension, dizziness, diarrhea, inflamed mucous membranes

Management: IV fluids Antibiotics Client education: 1.change tampons 3-6 hours 2.avoid tampons 6-8 wks after childbirth 3.do not leave diaphragms>48 hours

DIAPHRAGM
-mechanically blocks sperm from entering the cervix -soft latex dome supported by a metal rim -can be inserted 2 hours before intercourse; removed at least 6 hours after coitus or within 24 hours - must be refitted if the person gained 10 or more lbs or has given birth -size must fit the individual - initially fitted by a doctor -washable, may be used for 2-3 years

Client Instructions: A woman should be fitted by an obstetrician during the first if use & refitted after every delivery, abortion, & weight loss of at least 10 lbs. The largest size that fits the woman is chosen. Normally becomes brownish with use. Before inserting into the vagina, it should be inspected for tears & holes by holding it against the light Spermicide gel is applied at its rim before insertion

Diaphragm can be inserted 2 hours before coitus but must be left for 6 hours after intercourse. After use, diaphragm is washed with soap & water, dried with a towel & can be dusted with cornstarch. Do not use talcum powder, perfumed substances & petrolatum jelly because they may damage the diaphragm & irritate the vagina. It should be stored in a plastic container in a cool dry place. Can last 2-3 years

Endometriosis
Endometrial tissue outside the uterine cavity Pelvis most common location Bleeding results to inflammation, scarring of peritoneum and adhesions Cause unknown ( hereditary) Common in 20-45 yrs old

Common Sites 0f Endometriosis Formation

Manifestations: 1.Dysmenorrhea starting 1 or 2 days before menstruation & persisting for 2 to 3 days 2. Dyspareunia 3. Abnormal uterine bleeding 4. Fixed tender retroverted uterus 5. Palpable nodules in the cul de sac 6. Infertility Diagnostics: laparoscopy

Management: OCP-combination contraceptives to induce amenorrhea Analgesics for pain NSAIDS Danazol antiprogesterone; suppresses GnRH, low estrogen and high androgens to suppress ovulation, promote amenorrhea and decrease endometrial support GnRH agonists ie leuprolide suppress the menstrual cycle through estrogen antagonism Progestins ie Medroxyprogesterone antiendometrial effect

BREAST CANCER
** PRESENCE OF MALIGNANT TUMORS USUALLY IN THE UPPER OUTER QUADRANT OF THE BREAST. IT IS ASSOCIATED WITH NULLIPARITY OR HAVING THE FIRST CHILD AFTER AGE 35. 1.MOST COMMON NEOPLASM IN WOMEN

2. LEADING CAUSE OF DEATH IN WOMEN AGE 40 above

ASSESSMENT FINDINGS:
1.PALPATION OF LUMP (UPPER OUTER QUADRANT MOST FREQUENT SITE) USUALLY FIRST SYMPTOM 2. SKIN OF BREAST DIMPLED

3. NIPPLE DISCHARGE
4. ASSYMETRY OF BREAST

5. SURGICAL BIOPSY PROVIDES DEFINITE DIAGNOSIS

RISK FACTORS: Over age 40 Familial hx of breast cancer Early menarche Late menopause Nulliparous or birth of first child after age 34 High fat diet Oral contraceptive use Radiation exposure

MEDICAL MANAGEMENT: 1.USUALLY SURGICAL EXCISION; OPTIONS ARE SIMPLE LUMPECTOMY, SIMPLE MASTECTOMY, MODIFIED RADICAL MASTECTOMY AND RADICAL MASTECTOMY

2.TREATMENT WITH CHEMOTHERAPY, RADIATION AND HORMONE THERAPY

** PARTIAL MASTECTOMY = (LUMPECTOMY) REMOVAL OF LUMP & SURROUNDING BREAST TISSUE

**SIMPLE MASTECTOMY = REMOVAL OF THE BREAST ** RADICAL MASTECTOMY = REMOVAL OF THE BREAST, PECTORAL MUSCLES, PECTORAL FASCIA & NODES (PECTORAL, SUBCLAVICULAR, APICAL AND AXILLARY) ** MODIFIED RADICAL MASTECTOMY = RADICAL MASTECTOMY BUT PECTORAL MUSCLES ARE NOT REMOVED

MOST COMMON SITE OF METASTASIS:

** BONE, BONE MARROW, SOFT TISSUE, LUNGS, LIVER AND BRAIN.

**BREAST BIOPSY** 1. EXCISION =REMOVAL OF MASS FOR CYTOLOGIC STUDIES 2. INCISION= REMOVAL OF TISSUE FROM MASS OF CYTOLOGIC STUDIES 3. NEEDLE= (ASPIRATION) = REMOVAL OF TISSUE OR FLUID FROM MASS THROUGH A NEEDLE FOR CYTOLOGIC STUDY

LABORATORY DATA:
- MAMMOGRAPHY REVEALS THE PRESENCE OF NON-PALPABLE LESION.

- BASELINE MAMMOGRAPHY SHOULD BE MADE BETWEEN AGES 35-40.

NURSING INTERVENTIONS:
1. PROVIDE ROUTINE PRE-OP & POST-OP CARE. 2. ELEVATE CLIENTS ARM ON OPERATIVE SIDE ON PILLOWS TO MINIMIZE EDEMA. 3. DO NOT USE ARM ON AFFECTED SIDE FOR BLOOD PRESSURE MEASUREMENTS, IVS OR INJECTIONS 4. TURN ONLY TO BACK & UNAFFECTED SIDE

5. MONITOR CLIENT FOR BLEEDING ( CHECK UNDER AFFECTED ARM)

MENOPAUSE = PERMANENT CESSATION OF MENSTRUAL CYCLES THAT OCCURS BETWEEN 45 & 55 Y/O; ave: 50y/o = THE POINT AT WHICH NO FUNCTIONING OOCYTES REMAIN IN THE OVARIES

S/SX OF MENOPAUSE: 1.HOT FLASHES SENSATION OF HEAT THAT BEGINS IN THE FACE TO THE CHEST & PROFUSE PERSPIRATION. 2. LOSS OF BREAST MASS & FIRMNESS, ATROPHY OF REPRODUCTIVE ORGANS. 3. DYSPAREUNIA ( PAINFUL INTERCOURSE) DUE TO DECREASED VAGINAL LUBRICATION. 4. OSTEOPOROSIS - ESTROGEN PROMOTES CALCIUM DEPOSITION IN THE BODY. A FALL IN ESTROGEN LEVELS WILL LIBERATE CALCIUM FROM THE BONES MAKING THEM BRITTLE

MX:

1. ESTROGEN REPLACEMENT THERAPY ( HRT; ERT)

2. CALCIUM ( 1g/DAY AT HS) & VIT. D SUPPLEMENTATION 3. LIBERAL FLUID INTAKE TO DILUTE URINE AS MORE CALCIUM IS LIBERATED FROM THE BONES & COULD CAUSE RENAL CALCULI. 4. WEIGHT BEARING EXERCISES MX OF HOT FLASHES:

1. DRESS IN LAYERED LOOK, REMOVE OUTER CLOTHING DURING ATTACKS.

2. AVOID HOT ENVIRONMENT

3. AVOID EMOTIONAL STRESS 4. AVOID FOODS THAT COULD TRIGGER HOT FLUSHES: SPICY FOODS, COFFEE, TEA, ALCOHOL 5.USE COOLING TECHNIQUES: FANS, SHOWERS, ICE CUBES NURSING CARE:

1.ENCOURAGE WOMAN TO ENGAGE IN REGULAR EXERCISE PROGRAM TO MAINTAIN MUSCLE TONE

2. EMPHASIZE ADEQUATE INTAKE OF CALCIUM 3. VIT D FOR BETTER CALCIUM ABSORPTION. 4.INSTRUCT ON PROPER USE OF WATER SOLUBLE

VAGINAL LUBRICANT FOR PAINFUL INTERCOURSE.

5. INSTRUCT TO AVOID SMOKING & ALCOHOL

6. REGULAR PHYSICAL EXAMINATION.

Oral Contraceptives
Absolute Contraindications to OCs Breastfeeding Family history of CVA or CAD History of thromboembolic disease History of liver disease Undiagnosed vaginal bleeding

3. Oral Contraceptives
Possible Contraindications to OCs Age 40+ Breast or reproductive tract malignancy Diabetes Mellitus Elevated cholesterol or triglycerides High blood pressure Mental depression

Migraine or other vascular type headaches Obesity Pregnancy Seizure disorders Smoking Use of drug with interaction effect

Note: If you forget to take one pill, take it as soon as you remember. Continue the following day with your usual schedule. Doing so might mean taking two pills in one day, if you dont remember until the second day. Missing one pill this way should not initiate ovulation If you miss 2 consecutive pills, take 2 pills as soon as you remember & 2 pills again the following day. Then continue the following day with your usual schedule. You may experience some breakthrough bleeding with 2 forgotten pills. Do not mistake this bleeding for your menstrual flow. Missing 2 pills may allow ovulation to occur, so an added contraceptive should be used for the remainder of the month.

If you miss 3 or more pills in a row, throw out the rest of the pack & start a new pack of pills the following Sunday You might not have a period because of this routine & should use extra protection until 7 days after starting a new pack of pills.

Highly effective, weekly hormonal birth control patch thats worn on the skin Combination of estrogen and progestin Absorbed on the skin and then transferred into the bloodstream Can be worn on the upper outer arm, buttocks, upper torso or abdomen Worn for 1 week, replaced on the same day of the week for 3 consecutive weeks. No patch-4th week

Morning-after pills High level of estrogen Must be initiated within 72 hours of unprotected intercourse

Subcutaneous implants (eg, Norplant)

6 nonbiodegradable Silastic implants with synthetic progesterone embedded under the skin on the inside of the upper arm Slowly release the hormone over the next 5 years Suppress ovulation, stimulating thick cervical mucus and changing the endometrium so implantation is difficult

Intramuscular injections

-administered every 12 weeks Medroxyprogesterone (depo-provera) -100% effective

5.

INTRAUTERINE DEVICES

T-shaped plastic device with copper With progesterone Mechanism of action not fully understood Must be fitted by physician, nurse practitioner or midwife Insertion performed in ambulatory setting after pelvic examination and pap smear Inserted during menstruation Device is contained within uterus string protrudes into vagina Effective for 5-7 years (mirena type) or 8 years (Copper T380)

Side Effects: Spotting or uterine cramping Increased risk for PID Heavier menstrual flow Dysmenorrhea Ectopic pregnancy

Inability to conceive a child or sustain a pregnancy to childbirth

Pregnancy

has not occurred after at least 1 year of engaging in unprotected sexual intercourse

Types of infertility:

Primary infertility - refers to a couple who has never established a pregnancy Secondary infertility - refers to couple who has conceived previously but are currently unable to establish a subsequent pregnancy

Inadequate sperm count Obstruction or impaired sperm motility Ejaculation problems

Male factor:

Obstruction in the seminiferous tubules , duct, or

vessels preventing movement of spermatozoa Qualitative or quantitative changes in the seminal fluid preventing sperm mobility (movement of sperm). Problem in ejaculation or deposition preventing spermatozoa from being placed close enough to the womans cervix to allow ready penetration and fertilization.

Causes of inadequate sperm:

Chronic infection
Congenital anomalies Varicocele Increase in body temperature Trauma to the testes Endocrine imbalances Drug or excessive alcohol use Environmental factor

Obstruction or impaired sperm motility: Mumps or orchitis Anomalies of the penis Extreme obesity

Cervical problems Vaginal problems Unexplained infertility

Ovarian factor:
Anovulation- most common cause of infertility in

women 1. genetic abnormality 2.hormonal imbalance 3. ovarian tumor 4. stress 5.decreased body weight

Tubal factor:

Pelvic inflammatory disease

Uterine factor:

Tumor ( fibroma) Congenitally deformed uterine cavity Endometriosis Inadequate endometrium formation

Cervical factor: Characteristic of cervical mucus Infection/inflammation of cervix

Coital factor : pH of the vagina: alkaline pH is optimum (8) Presence of sperm-immobilizing/sperm agglutinating antibodies

Fertility testing Semen analysis Ovulation monitoring Tubal patency assessment

Number of sperm Appearance of sperm Motility of sperm Sperm penetration

count: 20 million / ml or 50 million /ejaculation volume: 2.5ml - 6 ml Motility: >75% Quality of motion: graded 1-4 (poor to excellent) Morphology: more than 70% normal

Record basal body temperature Ovulation by test strip Assesses upsurge of LH that occurs before ovulation

Sonohysterography -Ultrasound to inspect uterus Hysterosalpingography -Radiologic exam of fallopian tubes

Uterine endometrial biopsy Hysteroscopy Laparoscopy

Male factor:
Semen analysis Post-coital test-mucus is examined

microscopically between 2- 12hrs after coitus

Satisfactory test- many motile spermatozoa seen per high power field Unsatisfactory result: No spermatozoa are seen Majority of spermatozoa are immotile Very few spermatozoa are present

 Motility is characterized as shaking movement rather

than forward movement Hostile cervical mucus is present

Test of fertilizing capacity of spermatozoa:

Measurement of sperm acrosin-enzyme in sperm head that

responsible for preliminary changes in the sperm zona-free hamster ovum penetration test Human ovum fertilization test

Coital factor:
Taking history of coital frequency, pattern and technique Anatomic evaluation of the position of the cervix with

relationship to the vagina Post coital testing

Cervical factor: Cervix is the first major barrier encountered by sperm after arrival in the female reproductive tract
1.Abnormalities in the cervix or the cervical mucus

Abnormal position of the cervix( prolapse or uterine retroversion Chronic infection Previous cervical surgery Presence of sperm antibody in the cervical mucus

2.mucus quality: - pH -bacteriologic culture for microorganism

Uterine factor:

* role of uterus in reproduction: retention of the zygote after arrival from the fallopian tube provision of suitable environment for implantation protection of embryo /fetus from the external environment

Hysterography- visualize contour of the uterine cavity Hysteroscopy visualize uterine cavity to detect anomalous development, polyps or tumors

 Tubal factor:

- functions: 1.mechanical function- act to : -conveys recently ovulated ova into fallopian tube -permits spermatozoa to enter the oviduct -effects transfer of the blastocyst into the uterine cavity

Ovarian factor: -function: serve as repository for oocytes, they release mature oocytes at regular interval throughout reproductive life - secrete steroid hormones that influence the structure and function of tissue in reproductive tract, promoting fertility

*documentation of ovulation: a. basal body temperature records demonstrate a 14 day elevation of basal temp.( progesterone-thermogenic effect) b. Blood progesterone level c. endometrial biopsy- secretory endometrial pattern

Treatment : Correction of male factor: a. Medical - correction of underlying deficiencies - artificial donor insemination b. surgical - reversal of sterilization - varicocele surgery

c. assisted reproductive technologies 1. in vitro fertilization and embryo transfer IVF) 2. gamete intrafallopian tube transfer(GIFT) 3. assisted fertilization

Correction of ovarian factor: 1. induction of ovulation: - correction of underlying endocrine disorder - clomiphene citrate to correct hypothalamic function - human menopausal gonadotropin - bromocryptine for anovulation due to prolactin excess - glucocorticoids for androgen excess

Artificial insemination In vitro fertilization Gamete intrafallopian transfer Zygote intrafallopian transfer Surrogate embryo transfer

Artificial insemination instillation of sperm into the female reproductive tract to aid conception - technique of micromanipulation that thins the zona pellucida and inject sperm into the ovum in an effort to enhance fertilization In vitro fertilization (IVF) removing 1 or more mature oocytes from a womans ovary by laparoscopy and then fertilizing them by exposing them to sperm under laboratory conditions outside the womans body (placed on a dish together with the sperm) Embryo Transfer (ET) ova transfer; insertion of laboratory grown fertilized ovum into the womans uterus approx. 40 hours after fertilization where 1 or more of them will implant and grow
.

ARTIFICIAL INSEMINATION

IN VITRO FERTILIZATION

Gamete intrafallopian transfer (GIFT) ova and sperm are instilled in the patent fallopian tube within a matter of hours without waiting for the fertilization to occur in the laboratory Zygote intrafallopian transfer (ZIFT) retrieval of oocytes, culture and insemination of oocytes in the laboratory; fertilized eggs are transferred in the patent fallopian tube within 24 hours

Surrogate embryo transfer oocyte from a donor is fertilized by the recipient womans male partners sperm and placed in the recipients uterus by ET or GIFT

Intravaginal culture Blastomere analysis

ThAnK YoU Po!!!!