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MATERNAL HEALTH NURSING REVIEW OF THE FEMALE REPRODUCTIVE ANATOMY PELVIS Four Types: 1.

Gynecoid Pelvis Inlet is round Wide o Transverse diameter (TD) o Anteroposterior diameter (AD) This is the typical FEMALE PELVIS Most favorable for normal spontaneous delivery 2. Android Pelvis Wide o Transverse diameter o Anteroposterior diameter Anterior portion of AP diameter is converging o Therefore, it is HEARTSHAPED This is the typical MALE PELVIS 3. Anthropoid Pelvis Wide o Anteroposterior diameter Narrow o Transverse diameter This is the typical APE PELVIS 4. Platypelloid Pelvis Opposite of Anthropoid Pelvis Wide o Transverse diameter 1

Narrow o Anteroposterior diameter CLINICAL PELVIMETRY Part of routine clinical checkup Assessment of diameters of pelvis Nurse does the assessment Important Concept! X-ray pelvimetry is not done nowadays No outright caesarian section There is trial of labor COMPONENTS PELVIMETRY OF CLINICAL

1. Assess Sacral Prominence or Sacral Promontory Client in lithotomy position during Internal Examination Client should void before Internal Examination Minimal Draping Ready all equipment needed Source of light on pelvis Landmarks are: o Anterior landmark Symphysis pubis o Posterior landmark Sacrum Measure distance from SYMPHYSIS PUBIS TO SACRAL PROMINENCE o This distance must be greater than 11.5 centimeters!!! If this is satisfied, the first criteria is adequate!!! 2. Palpate for the side walls of the Vagina

Anxiety causes contraction of muscles in the perineum Normally, sidewalls of vagina are slightly convergent Despite the slight convergence, there is still some space that separates the walls of the vagina to facilitate passage of the fetal head If there is total convergence (due to contraction caused by anxiety) the head of the fetus would not emerge 3. Look at the pubic arch Palpate the roof of the pelvis o Normal or average is DOME-SHAPED Sacrum o Opposite the pubic arch o Palpate the floor of the pelvis the sacrum o There should be a depression o Normal depression is AVERAGE 4. Locate Ischial Spines Small bony projections on lateral side of pelvis Should be bilaterally NOT prominent DIAMETERS OF THE PELVIS Sagittal section Obstetric Conjugate A conjugate that CANNOT BE MEASURED CLINICALLY Distance from posterior surface of symphysis pubis up to the most prominent portion of sacral promontory

Subtract 1.5 2.0 cm from diagonal conjugate Therefore, Obstetric Conjugate (OC) is equal to Diagonal Conjugate (DC) minus 1.5 to 2.0 centimeters. In equation form: o OC = DC 1.5 or 2.0 cm Diagonal Conjugate Distance from anterior surface of symphysis pubis and the inferior margin of symphysis pubis up to the most prominent area of the sacrum Only conjugate that can be measured clinically Normal value is 11.5 cm to 12.5 cm. Important Concepts! Episiotomy is performed at the PERINEUM Perineum is the muscular portion between the vagina and the rectum Episiotomy is performed to o Prevent laceration (secondary) o Shorten the duration of the second stage of labor (this is the MOST IMPORTANT PURPOSE) as the head of the fetus will emerge quickly Two (2) ways of EPISIOTOMY Median Episiotomy o Cut is made from the vagina direct to the anus Mediolateral Episiotomy o To the right or left

Advantages of Median Episiotomy Has lesser blood loss because area cut has more fibrous tissue Less pain due to less nerves Disadvantages of Median Episiotomy Promotes extension to the rectum Therefore, there is greater degree of laceration Therefore, this is used most of the time This is the more common cut among the two types Advantages of Mediolateral Episiotomy Cut is done on the side of the perineal body This prevents extension (of the cut) into the rectum Therefore, there is less degree of laceration DEGREES OF LACERATION First Degree Laceration Skin Fourchette Posterior portion of vagina Posterior tip Subcutaneous tissues Second Degree of Laceration First three structures (mentioned in First degree laceration) plus PERINEAL MUSCLES Third Degree Laceration All of the structures in the second degree laceration plus RECTAL SPHINCTER Fourth Degree Laceration

All the structures in the third degree laceration plus RECTAL MUCOSA Important Concept! The greater the severity of the laceration, the longer recovery period is needed, the greater the chances for obtaining infections INTERNAL FEMALE REPRODUCTIVE STRUCTURES OVARY Ovulation is the most important function of the ovary Production of the female hormone Situated retroperitoneally Contained in the OVARIAN FOSSA In times of abdominal new growth in the ovary these are always detected late due to anatomical location Example: o Ovarian carcinoma o Ovarian malignancy Not easily palpable UTERUS Changes occurring during pregnancy Endometrium lining during pregnancy becomes deciduas (lining of the pregnant uterus) Endometrium is the lining of the NON-PREGNANT UTERUS Important Concept! There are three (3) DECIDUA 1. Decidua Basalis types of

Decidua immediately beneath the implantation of the blastocyst 2. Decidua Capsularis Decidua covering the blastocyst 3. Decidua Vera This is the remaining portion of the decidua Decidua that is not Basalis nor Capsularis Important Concepts! Clinical significance Desidua Basalis o Most important among the deciduas o Limits invasion of CHORIONIC VILLI into the MYOMETRIUM o Placenta will not be delivered spontaneously if basalis is NOT WELL DEVELOPED o This will result into a condition known as PLACENTA ACCRETA Placenta Accreta o Presence of faulty attachment of the chorionic villi of the placenta into the myometrium o The main problem in Placenta Accreta is HEMORRHAGE o Manual extraction is done o Raw edge leads to maternal hemorrhage o Therefore, the decidua basalis should be well developed

Important Concepts! Hegars Sign o Softening of the lower uterine segment o Prepares uterus during delivery as it accommodates the head of the fetus HYPERTROPHY of the muscles of the uterus occurs not HYPERPLASIA There is also increase in the VASCULARITY of the UTERUS FALLOPIAN TUBE Site of fertilization More specifically, the AMPULLA of the Fallopian Tube is the site of fertilization Distal Third of the Fallopian Tube Composed of the o Ampulla and Fimbriae Ampulla o Has the widest diameter among the segments of the fallopian tube Middle Third of the Fallopian Tube o Composed of the ISTHMUS Proximal Third of the Fallopian Tube o Composed of the INTERSTITIAL SEGMENT or the INSTERSTITIAL PART Important Concepts Ectopic pregnancy also occurs in the ampulla Eighty percent (80%) of tubal pregnancies are AMPULLARY

A patient with a HISTORY OF PELVIC INFLAMMATORY DISEASE due to sexually transmitted disease has defective or denuded cilia. This would lead to ectopic pregnancy MENSTRUATION Interplay between higher centers of the brain and the ovary Higher Centers of the Brain are composed of: o Hypothalamus Anterior Pituitary Gland HYPOTHALAMUS Produces GnRH or Gonadotropin Releasing Hormone Secreted in a pulsating manner Not sporadic This stimulates the ANTERIOR PITUITARY GLAND ANTERIOR PITUITARY GLAND Secretes GONADOTROPINS: o Follicle Stimulating Hormone (FSH) o Leutenizing Hormone (LH) When secreted, gonadotropins stimulates the ovary Ovary then secretes estrogen, progesterone Estrogen and Progesterone gives feedback to the uterus

H H AXIS Hypothalamus GnRH Anterior Pituitary FSH Ovary Estrogen Uterus H H AXIS Hypothalamus GnRH Anterior Pituitary LH Ovary Progesterone Uterus FEEDBACK MECHANISM If Estrogen / Progesterone increase in blood levels, this gives positive feedback to the Hypothalamus to decrease all hormones, all ovarian secretions If Estrogen / Progesterone decrease in blood levels, this gives negative feedback to the Hypothalamus to increase all hormones, all ovarian secretions OVARIAN CYCLE PROLIFERATIVE OR FOLLICULAR PHASE First half of the ovarian cycle Always variable in length Follicles of ovaries are growing

Uterus lining (endometrium) is proliferating Elevated Hormones Anterior Pituitary INCREASES SECRETION OF FOLLICLE STIMULATING HORMONE o Therefore, the follicle in the ovary ENLARGES o As it enlarges, it becomes more mature GRAAFIAN FOLLICLE o Most mature of all follicles o With cavity o With ovum ready to be extruded o With clear fluid rich in ESTROGEN o Only one (1) follicle matures per menstrual cycle Estrogen secretion effect in uterus Thickens the uterine lining Usually eight-fold of previous o From one millimeter to eight millimeter Peak of uterine lining coincides with ovulation Peaking of Estrogen will signal Leutinizing Hormone surge or increase in blood levels of Leutinizing Hormone LH Surge Coincides with ovulation Extrusion of ovum from the Graafian Follicle Signal for Ovulation Important Concept! Ovum stays in the Fallopian tube for one (1) to three (3) days Peak is twenty-four hours 6

LUTEAL OR SECRETORY PHASE Second half of the ovarian cycle Constant part o Always fourteen (14) days in length Production of Corpus Luteum o Uterus / uterine lining is secretory in nature Because of the secretion of Leutinizing Hormone o Leutinizing Hormone influences follicle o Cavity is left inside the follicle o Stimulates change in fluid in Graafian follicle o Yellowish, milky white fluid high in PROGESTERONE Progesterone Maintains uterine lining Organizes uterine lining o If only estrogen is present, the uterine lining would continue to thicken and thicken and thicken PRO-VERA o Progesterone o For dysfunctional uterine bleeding o For organization of the uterus Anticipates possible fertilization If there is pregnancy, to MAINTAIN PREGNANCY Important Concept! If ovum degenerates, o LH and Progesterone no longer needed

o Therefore, there is menstruation If there is coitus and fertilization Corpus Luteum must persist up to twelve (12) weeks of gestation After twelve (12) weeks, it degenerates and the placenta produces hormones Approximate menstrual cycle NORMAL is 28 days 28 + or 7 days or 21 35 days is also NORMAL If the menstrual period is short (i.e. 21 days), a person can menstruate twice in a month this is still NORMAL If a persons menstrual cycle is 28 days, 14 days for the proliferative or follicular phase and 14 days for the secretory or luteal phase, then OVULATION IS ON THE 14TH DAY If a persons menstrual cycle is 35 days, the OVULATION IS ON THE 21ST DAY Given the following: Last Menstrual Period (LMP) is January 1, 2005 Menstrual Cycle is 35 days January 2005 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 7

22 23 24 25 26 27 28 January 2005 continued. . . 29 30 31 February 2005 xx xx xx 01 02 03 04 05 06 07 08 09 10 11 Note that from the above information: The LAST MENSTRUAL PERIOD or LMP is the FIRST DAY OF THE PERIOD o Therefore, counting of the MENSTRUAL CYCLE, starts from this same date o Thus, February 4, 2005 Is the 35th day Is the expected start of the next cycle Is the LMP of the next cycle o Thus, February 3, 2005 Is the 34th day Is the end of the cycle that started on January 1, 2005 This is WHERE YOU START COUNTING BACK FOURTEEN DAYS TO GET THE DAY OF OVULATION o Therefore, count fourteen (14) days, starting February 3 going backward

o Thus, the expected OVULATION DAY is February 21, 2005 If the cycle is irregular, do not do this procedure If the Menstrual Cycle is not given, it is UNDERSTOOD THAT IT IS 28 DAYS DO NOT HAVE COITUS + OR THREE (3) DAYS OF EXPECTED TIME OF OVULATION o This may represent the fertile range o This gives enough time for the sperm to die and for the ovum to degenerate Interjected Concept! NAGELES RULE If LMP is from APRIL TO DECEMBER, use the formula o -03 +07 +01 (MM,DD,YY) If LMP is from JANUARY TO MARCH, use the formula +09 +07 (MM,DD) CONSTANT OF 11 AND 18 Another way of getting the ovulation period if the cycle is variable is by the use of the constant of 11 and 18 Example: o Menstrual Cycle is 22 35 days o Monitor the menstrual cycle in one years time o Subtract higher number (18) from shortest cycle 22 18 = 4

o Subtract lower number (11) from the longest cycle o 35 11 = 24 o Therefore, from the 4th to the 24th day of the cycle, there is NO COITUS o There is 80% failure in the rhythm method If menstrual cycle is 28 35 days o 28 18 = 10 o 35 11 = 24 o Therefore, from the 10th to the 24th day of the cycle, there is NO COITUS TERMINOLOGIES EMBRYO Product of Fertilization Lasts from time of fertilization (Day 0) to two (2) to three (3) weeks Pre-embryonic Period o Zero (0) to two (2) to three (3) weeks Embryonic Period o Two (2) to three (3) weeks to eight (8) to ten (10) weeks FETUS Eight (8) to ten (10) weeks up to time of delivery VIABILITY A fetus can be delivered Capable of living outside utero Period of Viability is TWENTY (20) WEEKS AND ABOVE

GRAVIDITY Number of REGARDLESS OUTCOME

pregnancies OF THE

82 / 7 is 11 and 5 / 7 weeks of pregnancy Therefore, present pregnancy is still not viable as 11 and 5 / 7 weeks is less than 20 weeks (age of viability) G1 G2 G3 G4 Positive for Parity Positive for Parity Just place one (1) even if Twin or more Negative for Parity; P < 20, just 6 Negative for Parity; P < 20, just 11 Therefore, woman is at G4P2!!! TPAL T is for Term (37 weeks and above) P is for Pre-term (20 to 36 weeks) A is for Abortion (any terminated pregnancy less than 20 weeks; 19 wks and below) L is for Living children In the above example: o T is 1 (G1) o P is 1 (G2) o A is 1 (G3) o L is 2 (G1 & G2) Therefore, the woman is o G4P2 T1P1A1L2 NULLIPAROUS Had been pregnant before Pregnancy did not reach age of viability 9

PARITY Number of pregnancies THAT REACH THE AGE OF VIABILITY REGARDLESS OF THE OUTCOME OF PREGNANCY (should be delivered) Example: Woman on 4th pregnancy 1st prenatal check-up by LMP is October 25, 2004 Date at Present is January 15, 2005 G1 Terminated at 38 wks AOG NSD 38 wks, NSD, 8 y /o G2 35 wks, CS, Twin A 5 y/o Twin B x (blood incompatibility; died after three days of birth G3 6 wks, Spontaneous abortion; Dilatation and Curettage G4 Present Therefore, the GRAVIDITY of the woman is G4! Compute for Age of Gestation (AOG) of current pregnancy to determine viability LMP is October 25, 2004 Current Date is January 15, 2005 o 06 days left in October o 30 days in November o 31 days in December o 15 days in January o 82 days pregnant

o Therefore, PRIMIGRAVID, NULLIPAROUS NULLIGRAVID Had never been pregnant MANIFESTATIONS PREGNANCY OF

o This releases pressure on the bladder Third Trimester o Uterus enlarges and presses again against the bladder in the Third Trimester 4. Nausea and Vomiting Human Chorionic Gonadotropin o Primigravida Mostly manifests this Peaks at FIRST TRIMESTER o At two (2) to three (3) months of pregnancy o At eight (8) to twelve (12) weeks of pregnancy Nursing Responsibility o Provide: Dry unsalted crackers Ice chips Small, frequent feedings Six (6) times a day This is the best among all the options Split food into two halves and give meals after every two (2) hours Less fatty foods in diet Do not lie supine after eating

Presumptive o More of a symptom rather than a sign Possible Positive PRESUMPTIVE SIGNS 1. Amenorrhea Ten (10) day allowance if you have regular menstruation period Ten days after expected period (+) pregnancy due to increased HCG; but this is not absolute 2. Breast Changes Tenderness and sensation This is not absolute tingling

3. Changes in Urination Urinary frequency o Present in First and Third Trimester o No Urgency Second Trimester o This disappears o Uterus starting to enlarge in First Trimester o Uterus becomes abdominal organ in the second trimester

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Encourage ambulation decreases

PROBABLE SIGNS More of the signs 1. Abdominal Enlargement Symmetrical and globular High risk Less than eighteen (18) weeks See different Landmarks: If uterus is at the level of the symphysis pubis o Age of Gestation = 12 weeks If uterus is midway between umbilicus and symphysis pubis o Age of Gestation = 16 weeks If uterus is at the level of the umbilicus o Age of Gestation = 20 weeks Then, increase of one centimeter (1 cm) in FUNDIC HEIGHT = Additional Four (4) weeks in Age of Gestation o 1 cm above the umbilicus = 24 wks o 2 cm above the umbilicus = 28 wks o 3 cm above the umbilicus = 32 wks o 4 cm above the umbilicus = 36 wks At the LEVEL OF THE XIPHOID PROCESS, Age of Gestation is 36 weeks If one centimeter (1cm) below the xiphoid process, Age of Gestation is 40 weeks due to LIGHTENING (presenting part enters the true pelvis) or DESCENT

Important Concept! Progesterone gastric emptying!

If nausea and vomiting is severe o Consider o Hydration o Vomiting o Hypokalemia, presenting as generalized weakness o Electrolyte Balance Therefore, client needs to be admitted 5. Fatigue Diaphragm does not descend upon inspiration 6. Skin Changes Brought about by hormonal changes - ESTROGEN o Cloasma Mask of pregnancy Visible at the cheek o Melasma Darkening of the neck o Linea Negra From the symphysis pubis to the umbilicus o Striae Gravidarum Silvery in color Due to distention of the collagen of the abdomen as the uterus enlarges 11

Important Concept! Lightening or Descent occurs o In Primigravida Two weeks earlier o In Multigravida Occurs during the time of labor

2. BALLOTTEMENT When you tap the uterus, there is a sensation that something is sinking and floating Sinking and floating of fetus in the uterus Appreciat ed at sixteen (16) to twentyfour (24) weeks only After twenty-four weeks (> 24 weeks), NO BALLOTEMENT OCCURS This is because the size of the baby is greater in respect to the amniotic fluid 3. BRAXTON HICKS False labor Palpable uterine contraction Starts at approximately twenty-eight (28) weeks and above This is okay unless it does not give progressive cervical dilatation 4. CHADWICKS SIGN Bluish-purple coloration of the vagina due to increase in vaginas vascularity

Vagina becomes swollen due to estrogen and progesterone Increase in acidity of vaginal pH due to lactobacillus acidophilus Lactobacillus acidophilus protects the vagina from ascending infection but favors increased growth of candidiasis Candidiasis o This problem increases in pregnancy 5. GOODELS SIGN Softening of the cervix to ready cervix for dilatation and effacement Increased vascularity (red and bluish cervix) Hyperplasia and hypertrophy of cervical glands (uterus hypertrophy only) Increased cervical glands Increased cervical secretions Leukorrhea or white secretions Cervical secretions coagulation or clumping resulting into MUCOUS PLUG or OPERCULUM Operculum o Protects the baby and the placenta from ascending infection 6. HEGARS SIGN Softening of the lower uterine segment POSITIVE PREGNANCY TEST HCG levels determine this Ten (10) days after missed period, this can be detected

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Peak of level of HCG is ten (10) weeks Age of Gestation or 2 months Then it goes down Therefore, yield of positivity of pregnancy tests to go down after ten (10) weeks POSITIVE MANIFESTATIONS 1. FETAL HEART TONE 1.1) Ultrasound o Cardiac pulsation as early as six (6) to eight (8) weeks 1.2) Doppler o Fetal heart tone at ten (10) to twelve (12) weeks 1.3) Fetoscope / Stethoscope o Fetal heart tone at eighteen (18) to twenty (20) weeks 1.4) External Electronic Fetal Monitor o Fetal heart tone at twenty-four (24) weeks Age of Gestation 2. QUICKENING Quickening felt by the examiner is a positive sign of pregnancy Quickening felt by the mother is a presumptive sign In Primigravida o This occurs later than twenty (20) weeks In Multigravida o This occurs earlier than sixteen (16) weeks

3. X-RAY / FETAL SKELETON APPRECIATED X-ray on pregnant mother is okay as long as there is ABDOMINAL SHIELD This is done on the SECOND (2nd) or THIRD (3rd) TRIMESTER but NEVER DURING THE FIRST (1st) TRIMESTER 4. PULSATION OF HEART OF BABY THROUGH ULTRASOUND MATERNAL PHYSIOLOGY Pregnancy Duration o 280 days o 40 weeks o 10 lunar months METABOLIC CHANGES DURING PREGNANCY 1. WEIGHT GAIN Twenty-five (25) to thirty-five (35) pounds First Trimester o Four pounds (4 lbs.) o Only organogenesis occurs o No muscle growth Second Trimester o Eleven pounds (11 lbs.) Third Trimester o Eleven pounds (11 lbs.) Important Concepts! One (1) to two (2) pounds per week is the allowable weight gain during the FIRST (1 st) and SECOND (2nd) TRIMESTER On the LATE THIRD TRIMESTER (36 weeks and above), allowable weight gain

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is one pound per week (1 lb. / week) 2. WATER METABOLISM Four (4) to six (6) liters of water are retained during pregnancy Thirty to fifty percent (30% to 50%) of this amount can enter into the circulation (approximately 2 3 liters) to intravascular space This INCREASES the CARDIAC OUTPUR Therefore, pregnant people with HEART CONDITIONS are AT-RISK!!! Important Concept! Increased Progesterone o Relaxes smooth muscles o Decreases peripheral resistance Therefore, Blood Pressure should REMAIN THE SAME or should DECREASE DURING PREGNANCY Important Concept! Sodium o Dilutional Hyponatremia occurs in pregnancy due to increased water retention o Therefore, DO NOT RESTRICT SALT INTAKE DURING PREGNANCY Just maintain sodium intake of three (3) grams per day 3. PHYSIOLOGIC ANEMIA Due to increase in plasma value

o Dilutes circulating Red Blood Cells o Therefore, take the Complete Blood Count in the initial assessment to get the blood picture of the client Give iron supplementation o Do this is the second trimester because this is the time when iron stores are depleted o Best taken at night o Metallic taste is nauseus o Give with food o A gastric irritant o Followed by orange juice o Acidic environment provides greater absorption o Advise that client will have black stool o Client taking iron is constipated o Therefore, increase oral fluid intake and iron 4.CARBOHYDRATE METABOLISM Pancreas is enlarged o Increased insulin secretion o Pregnancy is a diabetogenic state o A paradox!!! If pre-pregnant mother is diabetic o Two to three percent (2% to 3%) chance of having gestational diabetes

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o Placenta COUNTERACTS INSULIN by INSULINASE o Insulinase breaks insulin Human Placental Lactogen o Secreted only during pregnancy o Promotes lipolysis INSULINASE and HUMAN PLACENTAL LACTOGEN o Increased sugars in blood prevents starvation of baby in case of maternal starvation

PRENATAL CLINIC 1. HISTORY 2. PHYSICAL EXAMINATION 2.1) Take Blood Pressure Well rested mother for fifteen (15) minutes Blood Pressure Variations with Position Sitting o BP is slightly higher o Highest reading of the three positions Supine o Intermediate reading Left Lateral o Lowest reading among the three positions 2.2) IPA In pregnant women, assessment would consist of: o Inspection o Palpation o Auscultation NO PERCUSSION 2.3) FOCUS ON ABDOMEN Inspection o Look for striae o Look for hernia of umbilicus Palpate o Take the fundic height o Supine position with both legs flexed o Use centimeter scale of tape measure o Place at TIP OF SYMPHYSIS PUBIS up to the level of FUNDUS AND NOTE THE MEASUREMENT

5. PROTEIN METABOLISM Increase in need of protein during pregnancy Additional ten grams (10 g) of protein per day to be added to non-pregnant diet Important Concept! Placenta is made up of fatty acids FAT METABOLISM o Add to diet o A little increase in fat in the diet is necessary Important Concept! Iron supplementation in pregnancy is DOUBLED In pre-pregnancy o Fifteen grams per day (15 g / day) In pregnancy Thirty grams per day (30 g / day)

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2.4) PERFORM LEOPOLDS MANEUVER Purpose of Leopolds Maneuver o To know where the fetal back is o To get Fetal Heart Tone Important Concepts! Let patient void before performing Leopolds Maneuver In the first three maneuvers, the nurse FACES THE HEAD PART OF THE MOTHER 2.4.1) LEOPOLDS 1 Performed to know. . . What part of the baby occupies the fundus of the uterus? FUNDAL GRIP How is Leopolds 1 done? Use both hands Palpate the fundus of the uterus in a circular manner Locate if the fundus has: o HEAD Round Hard Ballottable mass o BREECH (buttocks) Soft Irregular With nodulations (coccyx, bilateral aspect of buttocks) Question: What Leopolds maneuver will you use to know the presentation of the fetus? Answer: 16

Leopolds 3 Important Concept! In Leopolds 1, we know what is the LIE of the baby FETAL LIE o Is the relationship of the long axis of the mother to the long axis of the baby Types of Fetal Lie Transverse Lie o Baby is perpendicular to the long axis of the mother o HORIZONTAL ORIENTATION Longitudinal Lie o Baby is parallel to the long axis of the mother o VERTICAL ORIENTATION KEY CONCEPT! If baby is in a TRANSVERSE LIE, LEOPOLDS 1 is NEGATIVE LEOPOLDS 2 Performed to know. . . Where is the FETAL BACK? Where is the UMBILICAL GRIP? How is Leopolds 2 done? Use both hands Palpate the side of the mother If at longitudinal lie o Fetal Back Bony, convex mass represents the vertebral column o Fetal Small Parts Small, irregular mass represents

the knuckles and knees If at transverse lie o Head or Buttocks will be located Important Concept! If you locate the back, place stethoscope at the back where FETAL HEART TONE is MOST AUDIBLE LEOPOLDS 3 Performed to know. . . What part of the baby lies just above the pelvic inlet PAWLIKS GRIP How is Leopolds 3 done? Use dominant hand Grasp area just above the symphysis pubis If you grasp the head o Round o Hard o Ballotable mass If breech o Soft o Irregular o With nodulations (coccyx, bilateral aspect of buttocks) Important Concepts! You will ALSO KNOW if PRESENTING PART IS ENGAGED or NOT ENGAGED If head is engaged, o If head is already descended, you will not feel the head o If head has not descended fully to the pelvic inlet (partial 17

descent), you can feel for the shoulders of the baby o If head is unengaged, you can grasp head and you can move it sideways KEY CONCEPTS! FETAL PRESENTATION is best determined by LEOPOLDS 3 because IT IS DIRECT. LEOPOLDS 1 is INDIRECT LEOPOLDS 4 Performed to know. . . What is the ATTITUDE of the fetus? FETAL ATTITUDE o This is the degree of flexion of the baby in utero Types of Fetal Attitude o Flexed Suboccipitobregmatic diameter is presented Approximately nine centimeters (9cm) Note: Bregma is anterior Extended It cannot pass through suboccipitomental diameter, which is greater than thirteen centimeters (>13 cm) Thus, there will be LONG LABOR Cervical Dilatation will not proceed Therefore, CAESARIAN

SECTION is PERFORMED You also note the DEGREE OF FLEXION or ATTITUDE of the fetus or PELVIC GRIP How is Leopolds 4 done? Face the foot part of the mother Use both hands Palpate the side of the mother going to the midline of the symphysis pubis If in complete flexion, o When you palpate the side of the mother, there is NO RESISTANCE o Note: Since there is no resistance, your hand moves down continuously If in extension attitude o There is RESISTANCE o This occurs when you hit NAPE AREA o Note: Your hand will feel a depression and then will feel the ascending curve going towards the head If in complete flexion o Cephalic prominence is on the same side as fetal small parts (feet and knees) If in complete extension o Cephalic prominence is on same side of fetal back KEY CONCEPT! Two (2) things to know from LEOPOLDS 4

o Fetal Attitude or the degree of flexion o Cephalic Prominence Important Concept! Prepare psychologically natal check-up mother during pre-

PSYCHOLOGICAL TASKS OF THE MOTHER FIRST TRIMESTER Mother should accept that she is pregnant (though ambivalence may be present) Concern of the mother towards herself is greater than her concern towards the baby SECOND TRIMESTER Acceptance of baby is the main task Concern towards the self is EQUAL to concern for the baby THIRD TRIMESTER Acceptance of parenthood Concern for the self is LESS than concern for the baby LABOR THEORIES OF PARTURITION FETAL SIGNAL The baby feels that it is already capable of living outside utero Example: o Fetus with Normal Spontaneous Delivery go into Post Maturity, delivered 42 43 weeks 18

o This is because fetus feels something is still lacking in his or her body OXYTOCIN THEORY OF PARTURITION Receptors for oxytocin in the uterus increases as term approaches PROGESTERONE WITHDRAWAL THEORY Level of progesterone assayed in pre-term and term pregnancy Pre-term o Progesterone level is still high Approaching Term o Level of progesterone DECREASES causing CONTRACTION OF THE UTERUS PROSTAGLANDIN THEORY Premature o Low levels of prostaglandin Term / Post Term o High levels of prostaglandin Important Concepts! o Prostaglandin causes uterine contraction COITUS is CONTRAINDICATED if you have a history of PREMATURITY since SEMEN CONTAINS PROSTAGLANDIN FACTORS AFFECTING LABOR

1. PELVIC DIMENSION 2. FETAL DIMENSION A) Fetal Size Correlation of size of baby to pelvic size Cephalopelvic Disproportion (CPD) Head of baby is INCONGRUENT with the pelvis Head Size is greater than the Pelvis Important Concept! Despite the presence of CPD, there is TRIAL OF LABOR and NOT OUTRIGHT CAESARIAN SECTION (unless there is outright indication) Number of Caesarian Sections in hospitals should not be more than twenty percent (20%) of all deliveries B) Fetal Posture or Attitude If in complete extension, labor will not progress C) Fetal Lie If fetus is in TRANSVERSE LIE, DILATATION will NOT PROGRESS D) Fetal Presentation If breech and PRIMIGRAVIDA NO NORMAL SPONTANEOUS DELIVERY If breech and MULTIGRAVIDA POSSIBLE NORMAL SPONTANEOUS DELIVERY

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E) Fetal Position Relationship of the four (4) quadrants of the pelvis of the mother to the presenting part F) Fetal Station Relationship of presenting part to ISCHIAL SPINES If head of baby descends in the pelvis, the head of the baby is AT THE LEVEL OF THE ISCHIAL SPINE THEREFORE, STATION IS ZERO 1 cm above ischial spine = -1 2 cm above ischial spine = -2 3 cm above ischial spine = -3 4 cm above ischial spine = -4 Important Concepts! At station of 4, head is still floating The presenting part is in the FALSE PELVIS The LINEA TERMINALIS is an imaginary dividing line that divides the FALSE and TRUE PELVES Above the linea terminalis is the FALSE PELVIS Below the linea terminalis is the TRUE PELVIS If engaged, head is not necessarily at STATION ZERO From STATION 3, the head is ALREADY ENGAGED!!! Below the Ischial spine, the reckoning is POSITIVE 1 cm below ischial spine = +1 2 cm below ischial spine = +2 20

3 cm below ischial spine = +3 4 cm below ischial spine = +4 Important Concept! At station +4, head is already CROWNING or SHOWING AT THE INTROITUS 3. FETAL HEAD Fontanelles o Give rise to molding Molding o Overlapping of sutures to accommodate head through the pelvis Anterior Fontanelle o Diamond shaped o Closes at nine (9) to eighteen (18) months Posterior Fontanelle Triangular shaped Closes at two (2) to three (3) months

UTERINE CONTRACTION TRUE LABOR Starts at lumbar area or the back Regular interval Progressive cervical dilatation and effacement Intensity is increasing Ambulation intensifies uterine contraction in true labor Sedation has no effect FALSE LABOR Confined to hypogastric area or lower abdomen Irregular interval

No cervical dilatation and effacement No change or decreasing intensity Ambulation stops uterus contraction Sedation stops false labor UTERINE CONTRACTION Timing is done by the nurse Use balls of the finger and palpate fundus of the uterus In the United States, the mother is hooked to an external monitor Example: Contraction starts 7:00 AM Lasts 60 seconds 7:01 AM Second contraction 7:04 AM Duration is 60 secs 7:05 AM Third contraction 7:08 AM DEFINITIONS: Interval o From end of first contraction to the beginning of the next contraction o 7:01 AM to 7:04 AM o Therefore, three (3) minutes Frequency o Beginning of one contraction to beginning of next contraction o 7:00 AM to 7:04 o Therefore, four (4) minutes Duration o From the beginning to end of one contraction o 7:00 AM to 7:01 AM o Therefore, one (1) minute 21

Intensity o This is a subjective term o May be classified as: Mild Contraction Examining finger can be indented but uterus is still contracting Moderate Contraction Examining finger can be indented but uterine contraction is more than in mild o Strong Contraction You cannot indent examining finger because the abdomen is board-like in consistency (hard) CLINICAL FINDINGS OCCUR PRIOR TO LABOR THAT

1. LIGHTENING In Primigravida o Two (2) weeks prior to labor In Multigravida o At time of labor 2. BRAXTON HICKS CONTRACTIONS Starting at twenty-eight (28) weeks Age of Gestation

This is normal, provided there is NO CERVICAL DILATATION

3. INCREASE IN VAGINAL SECRETION An attempt to remove mucous plug 4. SOFTENING OF THE CERVIX HEGARS SIGN For effacement and dilatation 5. BLOODY SHOW Secondary to descent presenting part Capillaries in the floor pelvis are ruptured presenting part or pressing the pelvis LABOR STAGE 1 TRUE UTERINE CONTRACTION TO FULL CERVICAL DILATATION (10 cm) For Primigravida (in normal circumstances) First Stage lasts for eight (8) to twelve (12) hours For Multigravida (in normal circumstances) First Stage lasts for six (6) to eight (8) hours In Precipitate Labor Entire labor is through within three (3) hours of of by on

o Zero centimeters (0 cm) to three (3 cm) Uterine Contraction o Duration Twenty (20) to Forty (40) seconds o Interval Five (5) to ten (10) minutes o Intensity Mild Intensity

PHASE 1 LATENT PHASE OF FIRST STAGE OF LABOR Cervical Dilatation 22

PHASE 2 ACTIVE PHASE OF FIRST STAGE OF LABOR Cervical Dilatation o Four centimeters (4 cm) to Seven (7 cm) Uterine Contraction o Duration Thirty (30) to Fifty (50) seconds o Interval Two (2) to Five (5) minutes o Intensity Moderate Intensity PHASE 3 TRANSITIONAL PHASE OF FIRST STAGE OF LABOR Cervical Dilatation o Eight centimeters (8 cm) to ten (10 cm) Uterine Contraction o Duration Up to sixty (60) seconds o Interval Two (2) to three (3) minutes

o Intensity Strong Intensity GENERAL NURSING MANAGEMENT IN THE FIRST STAGE OF LABOR Internal Examination identified Therefore, 1st Stage 1. Establish rapport with client Gain trust Decrease anxiety to decrease pain perception

2. Establish baseline information Assess the following: Gravidity o (if 5 or 6, risk for uterine atony) Parity Age o (if > 35, high risk) Contraction o When did it start? o Time of uterine contraction o How frequent is the contraction? Membranes o Is there watery vaginal discharge? o If the client identifies that there is watery discharge Perform sterile operculum examination Choose right speculum Use appropriate size Put on uni / bilateral gloves

Pick up speculum with long forceps (use nondominant unsterile hand) Wash or flush NSS on speculum to decrease its temperature (coming from the autoclave) Non-dominant hand is not gloved to hold speculum Dominant hand (gloved) separates labia (use thumb and little finger) then introduce middle and index finger; then depress perineum a little bit Insert speculum Beak on side Vertical then horizontal Downward and forward Once inside speculum, you can twist Push until there is resistance Then press handle so speculum will open Ungloved hand will operate the lock

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Speculum now hanging on cervix Have good source of light Look at cervical opening If there is RUPTURE OF MEMBRANE There is pooling of AMNIOTIC FLUID Color of Amniotic Fluid o Water-like, clear with some white specks o Cheesy vernix If greenish o Meconium Hypoxia is effect o Meconium aspiration syndrome o Plugs airway leading to hypoxia o Also leads to secondary infection o Meconium is produced in GUT at ten (10) weeks AOG o It is passed out if the fetus is out of the uterus (extrautero) or if there is ASPHYXIA or DISTRESS Towards the end of speculum examination: Remove speculum Unlock Press handle a little Important Concepts! For Meconium staining Use NITRAZINE TEST

o To determine whether fluid is amniotic fluid or urine pH Nitrazine paper is placed in contact with vaginal secretion Amniotic Fluid is ALKALINE o If pH nitrazine paper turns GREEN (ANY TINGE OF GREEN), IT IS AMNIOTIC FLUID Urine is ACIDIC o If pH nitrazine paper turns RED (ANY TINGE OF RED / ORANGE) Important Concept! Note the time when Rupture of Membrane occurs (ROM) Golden Period is twenty-four (24) hours If membrane has ruptured for greater than twenty-four hours (and STILL NO BIRTHING FROM LABOR), INFECTION WILL OCCUR. Therefore, a CAESARIAN SECTION IS NEEDED 3. Previous MEDICAL HISTORY OBSTETRIC COMPLICATION 4. TIME OF LAST MEAL / DRINK For Caesarian Section o It should be NPO For aspiration if CS or NSD o It limits use of anesthesia if patient had a meal Normal Spontaneous Delivery (NSD) o Normal anesthesia:

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General Anesthesia via I.V. or sedation (not given with a full stomach) o If client had a meal and has a full stomach, client will gag and aspirate o Therefore, use REGIONAL or LOCAL ANESTHESIA Medications: o Alcoholic mothers Sedation takes a longer time to take effect 5. ESTABLISH MATERNAL VITAL SIGNS First Stage - LATENT PHASE The following are taken every FOUR (4) HOURS: o Temperature o Respiratory Rate o Pulse Rate This is taken EVERY HOUR: o Blood Pressure First Stage - ACTIVE PHASE The following are taken EVERY HOUR: o Temperature (if ROM has occurred, this is done to check for infection) o Respiratory Rate o Pulse Rate Blood Pressure o This is taken EVERY THIRTY (30) MINUTES

First Stage - TRANSITIONAL PHASE (UP UNTIL BIRTH OF BABY OCCURS) The following are taken EVERY HOUR: o Temperature o Respiratory Rate o Pulse Rate Blood Pressure o This is taken EVERY FIFTEEN (15) MINUTES Important Concept! Do not take blood pressure if there is contraction There is false high blood pressure if there is contraction due to pain Remember, PAIN INCREASED BLOOD PRESSURE 6. CHECK FETAL HEART TONE First Stage LATENT PHASE o Taken EVERY HOUR First Stage ACTIVE PHASE o Taken EVERY AFTER EACH UTERINE CONTRACTION (UP UNTIL BIRTH OF BABY TAKES PLACE) 7. ASSESS FOR CERVICAL DILATATION AND EFFACEMENT BEFORE INTERNAL EXAMINATION Take Fetal Heart Tone first before doing the speculum examination Important Concepts! Fetal Heart Tone Is ALL or NONE

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Therefore, BEFORE MANIPULATING, take FHT first before Internal Examination and Speculum If client complains of ROM, o Do speculum first before Internal Examination so as not to disturb amniotic fluid o Hook client to external fetal monitor Check for patterns EXAMINATION TIP! What will you do first? Monitor Vital Signs o This is USUALLY an INCORRECT OPTION. Therefore, ELIMINATE THIS! Notify Physician o Most of the time, THIS IS THE LAST THING YOU WILL DO!!! o Therefore, CHOOSE FROM THE LAST TWO (2) REMAINING OPTIONS Important Concepts! Main Nursing Problem during the FIRST STAGE OF LABOR o To ALLEVIATE PAIN or DISCOMFORT of client Common Board Question! Which of the following phases in the first stage of labor does the client feel most pain and discomfort? Answer: TRANSITIONAL PHASE

Rationale: Client loses sense of control in this most uncomfortable phase of the first stage of labor In Latent Phase o Client is still able to smile In Active Phase o Client is unable to smile In Transitional Phase o Mother is now frowning o Remove fingers from the uterus o This gives additional pain to the mother o Mother loses sense of time SECOND STAGE OF LABOR FROM FULL CERVICAL DILATATION UP TO DELIVERY OF THE FETUS In Primigravida o One (1) to four (4) hours long In Multigravida o Twenty (20) to forty-five (45) minutes only Common Board Question In a client in labor A primigravida client, when will you transfer the client from the labor room to the delivery room? a) if cervix is fully dilated b) if in active labor c) if in transitional labor (8 10 cm) d) anytime Answer:

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Letter A Important Concepts! If patient is Multigravida o Best time to transfer patient from the labor room to the delivery room is the TRANSITIONAL PHASE o Transfer the client even while she is at eight centimeters (8 cm) dilatation Second Stage of Labor MECHANISMS OF LABOR IN VERTEX OR HEAD PRESENTATION POSITION OF FETUS Relationship of the four (4) quadrants of mother to the presenting part Mother is facing you Symphysis pubis is ANTERIOR Vertebra of mother is POSTERIOR Where is the BULK OF THE BABY? Lithotomy position Divide the pelvis into four (4) imaginary quadrants o Identify the presenting part If vertex or head Locate the posterior fontanelle It is on LEFT OCCIPUT ANTERIOR (LOA)

LOA

Left Occiput Anterior

LOT

Left Occiput Transverse LOP

Left Occiput Posterior Direct Occiput Posterior If posterior fontanelle is directly opposite the vertical line

DOP

Direct Occiput Posterior

Direct Occiput Anterior If posterior fontanelle is directly opposite the horizontal line

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DOA

Reference point is the RECTUM o Left Sacro Anterior o Left Sacro Transverse o Left Sacro Posterior Common Board Question In labor, position of baby is LSA (Left Sacro Anterior) o Get FHT at the left above the umbilicus (near the thorax) If baby is in LMA (Left Mentum Anterior) o Get FHT at Right Important Concept! Therefore, IF MENTUM, GET OPPOSITE DIRECTION If head is presenting o Below Umbilicus

Direct Occiput Anterior If baby is in extreme attitude Bulk of baby buttocks area If face presentation CHIN OR MENTUM

LMA

Left Mentum Anterior

LMT

RMA (Right Mentum Anterior) o Below umbilicus Important Concept! If head or breech, SAME SIDE AS BULK MECHANISM OF PRESENTATION Engagement Descent Flexion Internal Rotation Extension External Rotation Expulsion VERTEX

Left Mentrum Transverse

LMP

Left Mentum Posterior Important Concepts! Note: THERE IS NO DIRECT MENTUM ANTERIOR If the baby is in flexion and presenting part is breech. . .

Common Board Questions Give the correct sequence of the mechanisms of labor 28

Correlate the position of the head to the mechanisms of labor Important Concept! Engagement and Descent come together Lightening o Pertains to mother o Is also known as DESCENT o Tidal volume no longer decreased when lightening or descent occurs o Upon lightening, head meets resistance of the pelvic floor o Tendency of the head is to flex R / LOT or RIGHT / LEFT OCCIPUT TRANSVERSE when head of baby is in the pelvis After engagement, descent and flexion, there is INTERNAL ROTATION o Anterior Fontanelle is at posterior o Therefore, Posterior Fontanelle is at ANTERIOR o Head is in R / LOA o RIGHT / LEFT OCCIPUT ANTERIOR o Or in R / LOP o RIGHT / LEFT OCCIPUT POSTERIOR at Internal Rotation After Internal Extension occurs Rotation,

In Extension, Head is in DOA / DOP o DIRECT OCCIPUT ANTERIOR / DIRECT OCCIPUT POSTERIOR Important Concepts! OP (OCCIPUT POSTERIOR) o Mostly in Caesarian Section OA (OCCIPUT ANTERIOR) o Mostly in Normal Spontaneous Delivery External Rotation is also known as RESTITUTION Baby assumes original position intra-utero Internal Rotation is the same as External Rotation (when Internal Rotation is complete) o Head is in R / LOA or OP o Head is in R / LOA o RIGHT / LEFT OCCIPUT ANTERIOR o Or in R / LOP o RIGHT / LEFT OCCIPUT POSTERIOR at External Rotation During Expulsion, head is in LOT o LEFT OCCIPUT TRANSVERSE Main Problem in Second Stage of Labor is STILL PAIN

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Important Concept! Therefore, nursing management is focused on the ALLEVIATION OF PAIN!!! THIRD STAGE OF LABOR DELIVERY OF BABY DELIVERY OF PLACENTA TO

Lasts for five (5) to ten (10) minutes Maximum waiting time is thirty (30) minutes Beyond thirty (30) minutes is ALREADY ABNORMAL SIGNS OF PLACENTAL EXPULSION 1. Calkinss Sign o Uterus becomes firm and globular 2. Lengthening of the Cord 3. Sudden Gush of Blood 4. Rising of the Uterus into the Abdomen o Up to the level of the umbilicus or one centimeter (1 cm) after umbilicus after the delivery of the placenta Two (2) Types Expulsion Shultz Duncan of Placental

SHULTZ MECHANISM OF PLACENTAL EXPULSION Shiny Cotyledon is not seen Total membrane covers this Placental separation starts at fetal side of the placenta o This is the membrane Central separation is the start

Less chances of bleeding Nursing Responsibility for the Assessment of the Placenta o Expose all cotyledons If one is missing, IT REMAINS INSIDE Look for the PUNCHED-OUT AREA o Measure the placental diameter o Weigh the placenta Remove the clamp Normal placental weight Less than 500 grams If greater than 500 grams, there is PLACENTOMEGALY related to congenital anomaly o Measure umbilical cord Measure portion of the cord remaining with the placenta Measure portion of the cord remaining with the baby If this is less than fifty centimeters (<50 cm), there may be SHORT CORD SYNDROME related to

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o o o

ABRUPTIO PLACENTA Expect Blood Vessels Artery Small round lumen Vein Bigger lumen More collapsed Two (2) arteries and one (1) vein Mnemonic is AVA If there is only one (1) artery and one (1) vein, there is a congenital problem A GUT PROBLEM Genitourinary Tract Anomalies

o Best time to clamp the cord is when THE CORD STOPS PULSATING When is the best time to cut the cord? o Best time to cut the cord is when THE CORD STOPS PULSATING Pulsation means blood still flows Drugs for Third Stage of Labor These drugs cause contraction of the uterus 1. ERGOTRATES Includes METHERGINE I.V. or I.M. Best given immediately after delivery of placenta Massive contraction of the uterus traps placenta inside Therefore, do not give before placental expulsion 2. OXYTOCIN Given prior to expulsion of placenta to add to contraction Given at minimal amounts Normally at a rate of eleven to twelve drops per minute (1112 gtts / min) After delivery of placenta, give oxytocin at GREATER AMOUNTS Important Nursing Considerations! Methergine o Prior to administration, check blood pressure

DUNCAN MECHANISM OF PLACENTAL EXPULSION Placental separation starts at SIDE / PERIPHERY on the lower end of the placenta Placenta slides down to the introitus Maternal side presents (attached to myometrium) Cotyledons are easily visible Associated with more bleeding and hemorrhage Important Concepts! Normal Range of Number of Cotyledons o Sixteen to twenty (16 20) When is the best time to clamp the cord?

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o If BP is greater than 140/90, WITHHOLD METHERGINE Oxytocin o Never given in direct bolus o Never push o Causes UTERINE HYPERTONUS Tetanic contractions of the uterus or UTERINE ATONY o Always dripped Ten (10) units with one (1) liter o Duration and Interval of Contraction in Uterine Atony / Hypertonus o Duration of Contraction Greater than seventy seconds (>70 secs) In Transitional Phase of First Stage of Labor, duration of contraction is about sixty (60) seconds o Interval Less than two (2) minutes This means that rest period is decreased Maximum interval must be maintained at two (2) to three (3) minutes Therefore, STOP INFUSION OF OXYTOCIN AS SOON AS POSSIBLE

DO PROCEDURES IN LATE DECELERATION Additional Important Concepts! Oxytocin o A potent vasoconstrictor o Side effect Initially is HYPERTENSION o If given in bolus Hypertension will be REVERSED TO HYPOTENSION Therefore, DO NOT GIVE OXYTOCIN IN BOLUS Also causes WATER INTOXICATION o Therefore, assess lungs of client o Crackles will be present due to pulmonary edema due to water retention by oxytocin Primary Problem in Third Stage of Labor Bleeding or Hemorrhage Important Concepts! Uterus must be at level of umbilicus or about one centimeter (1 cm) above If it is three centimeters (3 cm) above the umbilicus, UTERUS IS NOT CONTRACTED o There would be BLEEDING First thing to do: o Massage the uterus to attempt contraction o Increase the rate of oxytocin drip

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Nurse does this Rate is increased from ten drops per minute (10 gtt/min) to twelve to fifteen drops per minute (12 15 gtt/min) o Place icepack over the abdomen Remove compress every ten minutes and replace This prevents necrosis and blackening of the tissues Inspect Perineum o How to measure amount of bleeding? o Utilize the PADS Count and Weigh Guide: One gram is equivalent to one milliliter (1 g = 1 ml) o Qualitative Approach Mild Bleeding One (1) pad saturated in one (1) hour Moderate Bleeding One (1) pad saturated in thirty (30) minutes

Heavy Bleeding One (1) pad saturated in fifteen (15) minutes

Heavy Bleeding Perineal pads saturated at one (1) hour and if blood clots are present o Palpate Abdomen Uterus contracted Perineum has bleeding Bleeding from episiotomy (done if there is crowning or +4 station) Laceration not appraised o Bleeding from cervical laceration Most common cause of bleeding o Vaginal wall bleeding Important Concept! DO NOT ENCOURAGE PUSHING IF CERVIX IS NOT FULLY DILATED Question When is the best time to ask client to push?

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Answer Second Stage of Labor Important Concepts! Main purpose of pushing o To shorten the Second Stage of Labor Ask client to PANT-BREATHE if there is an urge to push This prevents VALSALVA MANEUVER Rememb er, FIRST STAGE PUSHING IS NOT ADVISABLE In the Third Stage of Labor, the NURSING RESPONSIBILITY is to PROVIDE MEASURES TO PREVENT HEMORRHAGE Other Causes of Bleeding Bladder Distention o Therefore, MOTHER MUST VOID AFTER GIVING BIRTH o Offer bedpan every hour or accompany the mother to the bathroom (patient has HYPOTENSION) o First twelve (12) hours post partum It is NORMAL for mother to go into DIURESIS Absorbed water must be eliminated o After twelve (12) hours, there is difficulty in voiding due to FATIGUE of TRIGONE of BLADDER because

of CONSTANT PRESSURE EXERTED BY CONTRACTING UTERUS This results to a DISTENDED BLADDER Therefore, UTERUS CANNOT CONTRACT EFFECTIVELY This causes UTERINE ATONY (Uterus is deflected either to the LEFT or to the RIGHT) Therefore, assure voiding so uterus stays at center Place warm water in container o Do not place warm water in abdomen or at the hypogastric area o This will cause bleeding Nursing Responsibility o Do alternate pouring of warm and cold water over the perineum to promote uterine contraction FOURTH STAGE OF LABOR FIRST ONE (1) TO TWO (2) HOURS AFTER DELIVERY OF THE PLACENTA Crucial Problem or Problem at this stage o BLEEDING Main

34

All the retained water retained previously will be reabsorbed into the circulation o Increase in Cardiac Output o Increase in Oxygen Consumption Therefore, it is the most detrimental or difficult stage of labor in GRAVIDOCARDIAC PATIENTS!!! BLEEDING DISORDERS PREGNANCY ABORTION Two (2) types of Abortion Spontaneous Abortion Induced Abortion SPONTANEOUS ABORTION Most common cause spontaneous abortion CHROMOSOMAL NATURE Embryo is defective Tell the client that this Gods will of is IN IN

is

TYPES OF SPONTANEOUS ABORTION Threatened Abortion Incomplete Abortion Inevitable / Imminent Abortion Complete Abortion Missed Abortion (see attached table on Types of Spontaneous Abortion) Important Concepts!!! Danger in MISSED ABORTION is SEPSIS

Particularly if products of conception stay for more than two (2) weeks, there is INFECTION and DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC) DIC may also occur from induced abortion (abortion with catheterization) o Offending organism is gram negative anaerobe o Gram negative organism secretes ENDOTOXINS Causes destruction of capillaries Results in turbulence in blood flow Blood will seep out through the capillaries Platelets will go to site of destruction Platelets consumed Therefore, also called CONSUMPTIVE COAGULOPAT HY Disseminated Intravascular Coagulopathy patients: o Die of continuous bleeding o Have patches of hematoma o Have hypotension leading to SEPTIC SHOCK due to

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dilatation caused by ENDOTOXIN. In septic shock, the extremities are warm o All other forms of shock have COLD EXTREMITIES ECTOPIC PREGNANCY Mostly tubal in nature (95%) Can be abdominal pregnancy Can be ovarian pregnancy Abdominal and ovarian pregnancy account for five percent (5%) Eighty percent (80%) of total pregnancies are AMPULLARY Most common predisposing factor o PELVIC INFLAMMATORY DISEASE or PID Other factors: o Previous Surgery May lead to adhesion Peritoneum may adhere to fallopian tube o Presence of Intrauterine Device o History of previous ectopic pregnancy (on opposite side) TRIAD OF MANIFESTATIONS Amenorrhea Vaginal bleeding or SPOTTING UNILATERAL ABDOMINAL PAIN or TENDERNESS o Usually lower abdomen CLINICAL MANIFESTATIONS OF ECTOPIC PREGNANCY 36

Severe, sharp knife-like abdominal pain o Unilateral pain Abdominal rigidity o Bleeding inside o Hemoperitoneum o Peritonitis Positive (+) for Cullens Sign o Ecchymosis around the umbilicus due to hemoperitoneum Decreased Blood Pressure o About 80 / 50 Excruciating Pain when the cervix is moved WRIGGLING TENDERNESS Important Concepts! Perform Internal Examination Cervix is moved sideways, up and down Especially ruptured ectopic pregnancy Cervix is almost devoid of nerves Important Concepts! In ectopic pregnancy, blood goes to the peritoneum o Blood ruptures and pools at CUL DE SAC or the POUCH OF DOUGLAS or URETERORECTAL POUCH When internal examination is done and cul de sac is palpated, WRIGGLING SENSATION arises DIAGNOSIS PREGNANCY FOR ECTOPIC

CULDOCENTESIS You get something from the cul de sac How is Culdocentesis done? Consent Lithotomy position Prepare Perineum Speculum introduced o Held in place To visualize the cervix o No anesthetic is given Spinal needle directed towards posterior portion of the cervix Aspirate If blood is present in the cul de sac, it is a RUPTURED ECTOPIC PREGNANCY If there is blood. . . o It is tested to make sure it comes from ectopic pregnancy and NOT MATERNAL BLOOD o Blood is placed in a test tube / disk and observed for clotting If NON-CLOTTING OR LAKED BLOOD o It comes from ectopic pregnancy If BLOOD CLOTS o It is maternal blood MANAGEMENT PREGNANCY FOR ECTOPIC

and eventual absorption to the circulation If ectopic pregnancy is less than three centimeters (3 cm) o Given I.M. to the mother SURGICAL MANAGEMENT Salphingostomy Limited to UNRUPTURED (less than three centimeter (3 cm)) binubutas, tinatanggal Left to heal Salphingotomy Limited to UNRUPTURED binubutas, tinatanggal Sutured Salphingectomy For a ruptured pregnancy ectopic

H-MOLE Predisposing Factors: o Low socio-economic status o Low protein intake o Age Less than eighteen (<18) Greater than thirty-five (>35) PROBLEM IN H-MOLE There is an abnormal degeneration of the chorionic villi Vesicle-like structure is formed instead of placenta This is called KYAWA and described as UBAS-UBAS

MEDICAL MANAGEMENT METHOTREXATE A sclerosing agent o To shrink and absorb products of conception 37

MANIFESTATIONS OF H-MOLE Bleeding o PINKISH VAGINAL DISCHARGE Fundic height o LARGER THAN AGE OF GESTATION Fetal Heart Tone o Absent Pregnancy Induced Hypertension (P.I.H) o Occurs earlier because Human Chorionic Gonadotropin is very high in H-Mole NURSING RESPONSIBILITIES IN H-MOLE SUCTION CURETTAGE Sinisipsip Ayaw kayudin ang uterine lining Purpose of Suction Curettage o To prevent cancer of CHORIONIC CARCINOMA o To prevent bleeding o Sinuses Open Early dissemination of tissues or METASTASIS to the lungs, brain Lungs are the MOST of METASTASIS IN H-MOLE Monitor TITER OF HCG In Normal Pregnancy HCG titer is o 100,000 U to 400,000 U

In Molar Pregnancy or HMole, HCG titer is o 1,000,000 U to 2,000,000 U Close follow-up is MANDATORY Monitor level of beta-HCG level every one (1) to two (2) weeks until normal When normal, continue monitoring level of beta-HCG every two (2) to four (4) weeks for a duration of ONE (1) YEAR Important Concepts! Cancer or choriocarcinoma Patient may engage in coitus as long as she does not get pregnant Use condom or barrier method Confusing result of HCG due to pregnancy or choriocarcinoma INCOMPETENT CERVIX / CERVICAL OS Most common cause of Habitual Abortion Habitual Abortion o Three (3) consecutive abortions PREDISPOSING FACTORS IN INCOMPETENT CERVIX Developmental Factors o Defective collagen formation in the cervix Repeated Trauma to the Cervix o Repeated Dilatation and Curettage

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MANIFESTATIONS OF INCOMPETENT CERVIX Minimal uterine contraction Vaginal Spotting Progressive dilatation of the cervix Already evident in the FIRST TRIMESTER MANAGEMENT OF INCOMPETENT CERVIX McDonalds Procedure Shirodkar / Barter Procedure MC DONALDS PROCEDURE Purse string suture applied to cervical opening o Purpose is to make the cervix tense Done if products of conception IS LESS THAN TWELVE (12) WEEKS OLD Mother is allowed to deliver by NORMAL SPONTANEOUS DELIVERY if pregnancy persists SHIRODKAR / BARTER PROCEDURE Cervix is closed But menstrual blood is allowed to come out Delivery is via CAESARIAN SECTION NURSING RESPONSIBILITIES IN INCOMPETENT CERVIX Bed Rest Position of choice o Modified Trendelenberg o Lumbar area is elevated and feet are lowered Coitus is temporarily restricted

Tocolytic therapy is employed if there is contraction o RITODRIN, TERBUTALLINE is administered to STOP CONTRACTION PLACENTA PREVIA Important Concept! All previa types are CAESARIAN DELIVERIES !!! FOUR (4) TYPES OF PLACENTA PREVIA 1. Low Lying Placenta Previa Example: Gravida 7 Predisposing Factors o Multiparity o Tumor or mass in the uterus o Previous Caesarian Section Scar is avoided by the placenta o Developmental Anomaly in the Uterus Bicornuate uterus 2. Marginal Placenta Previa Lower end of Placenta is TOUCHING THE INTERNAL OS 3. Partial Placenta Previa Part of placenta is OBSCURING THE INTERNAL OS 4. Total Placenta Previa Also called Placenta Previa Totalis

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Placenta TOTALLY COVERS THE INTERNAL OS o Definitely a Caesarian Section! Localization of Placenta o Done on the second / third trimester PLACENTAL MIGRATION Placenta moves and may move up Can occur up to thirty-two (32) weeks Important Concepts!!! Establish that the placenta is NOT PREVIA in ALL INSTANCES OF SECOND OR THIRD TRIMESTER BLEEDING o Wait for the ULTRASOUND result o DO NOT DO INTERNAL EXAMINATION!!! DOUBLE SET-UP Client with placenta previa o If Internal Examination is done o A stand-by team for operation is set up Due to the advent of the Ultrasound, a Double Set-up is NO LONGER DONE!!! ABRUPTIO PLACENTA Normal Placement EARLY SEPARATION OF THE PLACENTA PRIOR TO DELIVERY OF THE FETUS

Remember that separation of placenta normally occurs on the THIRD STAGE OF LABOR In abruptio placenta, the abnormal separation OCCURS ON THE SECOND STAGE OF LABOR Important Concepts! If baby has SHORT CORD SYNDROME or TRAUMA, consider ABRUPTIO PLACENTA Pregnancy Induced Hypertension o A common cause of Abruptio Placenta Separation in Abruptio Placenta may be: PERIPHERAL SEPARATION Better Safer Blood goes out of introitus Tachycardia Hypotensive Increases degree separation Increases degree fluctuation of vital signs

of of

CENTRAL SEPARATION More dangerous Blood does not seep off through the introitus but enters MYOMETRIUM Results to difficulty in contraction of the Myometrium Uterus remains soft and boggy o Uterine Atony Therefore, HYSTERECTOMY IS DONE

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Called COUVELAIRE Uterus is COPPERCOLORED or BLUISH in color due to BLOOD THAT SEEPED INTO THE MYOMETRIUM COMPARISON OF PREVIA AND PLACENTA
PLACENTA PREVIA (-) Negative; Painless

PLACENTA ABRUPTIO
ABRUPTIO PLACENTA (+) Positive; There is RIGIDITY OF THE UTERUS Dark Red; Painful due to concealed hemorrhage Not heard because the uterus is hard boardlike Hard / Boardlike No Immediate CS / Abdominal delivery

Abdominal Pain

Bleeding

Bright Red and Painless Appreciated

Fetal Heart Tone (baby is alive) Uterine Consistency Fetal Outline Management

Soft Yes Expectant Management; Watchful Waiting

No Coitus Policy o Once diagnosis is done until delivery o Uterus contracts upon excitation o This results to bleeding Tocolytic Therapy o Beta 2 Agonists Smooth muscle relaxants Isoxoprine Terbutalline Ritrodrine / Ritopar o Magnesium Sulfate For tocolytic, especially of diabetic (Gestational Diabetes) Not a Beta 2 Agonist because it promotes lipolysis leading to increase in blood sugar Interjected Concepts! o Beta 1 Agonists Heart o Beta 2 Agonists Lungs o Use of Beta 2 Agonists expected side effects Tachycardia Restlessness Anxiety o Monitor Fetal Heart Rate (tachycardic) Mothers Blood Pressure Steroids

Expectant Management Watchful Waiting Limited When o Mother is hemodynamically stable o No fetal distress If there is bleeding or there is fetal distress, OUTRIGHT DELIVERY IS NECESSARY Components Management Bed Rest of Expectant

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o Given if mother is less than thirty-four (34) weeks o Examples: Bethametasone Dexamethasone o Purpose of Steroids To promote lung maturity Increases lung surfactant To decrease Respiratory Distress Syndrome o If Age of Gestation is greater than thirty-four (34) weeks, THERE IS NO NEED FOR STEROIDS BECAUSE SURFACTANT IS PRESENT Important Concepts! o Half life of steroids is one (1) week Therefore, repeat steroid administration if contractions are present PREMATURE RUPTURE OF MEMBRANES Membranes rupture PRIOR TO ONSET OF LABOR No contractions yet PROBLEMS IN PREMATURE RUPTURE OF MEMBRANES 1. INFECTION Gold Standard is twenty-four (24) hours If more than twenty-four hours, there will be SEPSIS 2. CORD PROLAPSE

Umbilical cord goes out Position the client to TRENDELENBERG POSITION o Lower the head part o NICHES POSITION Do not reinsert!!! Moisten OS with NSS and cover Push the PRESENTING PART BACK and NOT THE CORD Transport client to the OPERATING ROOM Provide oxygenation Get Fetal Heart Tone Then Caesarian Section is started Never Normal Spontaneous Delivery

MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES Pregnancy can still be prolonged if PRE-TERM PREMATURE RUPTURE OF MEMBRANES (PPROM) o Pre-term Premature Rupture of Membranes (i.e. 35 weeks) Problems are: o Infection o Cord Prolapse o Prematurity Provided o There is no maternal infection o There is no fetal distress o Mother is not in labor Termination of Pregnancy 42

o Caesarian Section o Normal Spontaneous Delivery PREMATURE LABOR Most common cause of neonatal morbidity and mortality o Eighty five percent (85%) Preventable o How? Modify lifestyle of the mother Resolve ongoing infection Ascending infection affects fetus, uterus (goes into contraction) Management is similar to Placenta Previa o Except coitus restriction throughout (in placenta previa, it is only temporary) Coitus restriction could only be temporary if there is no infection and no contraction of the uterus POST TERM LABOR Pregnancy extends beyond forty-two (42) weeks 1. Cephalopelvic Disproportion (CPD) This leads to babies with o Long nails o Wrinkled Skin 2. Oligohydramnios Amniotic fluid is less than 1,000 ml

Polyhydramnios is amniotic fluid level greater than 2,000 ml Related to congenital anomaly This gives rise to babies with BANDS OR CONSTRICTIONS ON BODY 3. Inadequate blood supply to the baby due to calcification of the placenta Placenta tends to harden There are whitish specks instead of black specks 4. Meconium Staining Due to distress Meconium Syndrome

Aspiration

PRECIPITATE LABOR Course of labor is ABRUPT Labor lasts for LESS THAN THREE (3) HOURS DANGERS OF PRECIPITATE LABOR Non-institutionalized Delivery o Exposes baby to sepsis Expose mother to laceration o Head of baby bumps to pelvis This results to hemorrhage Intracerebral hemorrhage of the head of baby o Baby bumps to bony pelvis BREECH DELIVERY 1. COMPLETE BREECH Baby assumes a position similar to sitting Thighs flexed to abdomen

43

Legs flexed to thigh 2. FRANK Thighs are flexed to abdomen Legs are extended 3. INCOMPLETE BREECH Thighs are flexed to abdomen Either leg is extended outside o Single Footling Double Footling MAIN PROBLEM Cord Prolapse o Space in cervical opening o Therefore, cord goes with presenting part Head Entrapment Shoulder Dystocia o Difficulty in bringing out shoulder Normal to see Meconium Staining o Buttocks get stuck o Less blood supply to the gut o Stress present o Therefore, there is meconium MULTIPLE PREGNANCY Two (2) types of Multiple Pregnancy Monozygotic Dizygotic MONOZYGOTIC One (1) ovum and one (1) sperm Fertilized by single sperm Problem in cell division Two (2) individuals Most of the time, of the same sex

One (1) placenta Two (2) umbilical cords One (1) chorion (vascular outer covering) o In contact with maternal side Two (2) amnions (avascular inner covering) o In contact with the fetus DIZYGOTIC Two (2) ova and two (2) sperms fertilizing them Identical or twin of opposite sex Two (2) placenta Two (2) umbilical cord Two (2) amnions Two (2) chorions Important Concepts! MONOZYGOTIC TYPE OF MULTIPLE PREGNANCY o More common Increased chance of twin to twin transfusion o Donor twin and recipient twin Blood of donor twin goes to recipient twin Because they share one vascular channel o Donor Twin Survives Usually thin Would normalize and be okay after blood transfusion o Recipient Twin Dies

44

Develops Congestive Heart Failure Usually stout

PREGNANCY INDUCED HYPERTENSION (P.I.H.) Unknown cause But HCG Vasospasm SCREENING PROCEDURE FOR PREGNANCY INDUCED HYPERTENSION 1. ROLL-OVER TEST Done when mother is o Twenty-eight (28) to thirty-two (32) weeks Age of Gestation With increased cardiac output o Mother is rested for fifteen (15) minutes o Take the blood pressure in sitting position (assuming BP is 100/60) o Rest mother for fifteen (15) minutes o Get blood pressure at left lateral position (assuming BP is 90/60) o Place mother in supine position o Take the BP in supine position (assuming BP is 120/80) o Then compare values at left lateral and immediately supine Important Concept! o Implication Positive Rollover test if there is an:

Increase in SYSTOLIC BP of 30 mmHg Increase in DIASTOLIC BP of 15 mmHg 100/60 90/60 120/80 30/20

In the above example: Base line BP = Left Lateral BP = Supine BP = Difference =

Therefore, this is positive for roll-over test Either systolic or diastolic, positive is positive Therefore, client has increased chance of developing Pregnancy Induced Hypertension TRIAD OF PREGNANCY INDUCED HYPERTENSION Hypertension after twentieth (20th) week of Age of Gestation Proteinuria o Greater than twohundred fifty milligrams per deciliter (>250 mg/dl) Edema o Pathologic o Physiologic Two (2) General Classifications Pre-eclampsia Eclampsia PRE-ECLAMPSIA Mild Severe

45

Mild Pre-eclampsia Blood Pressure o Positive to roll-over test o But blood pressure can go as high as 140/90 to 150/100 Proteinuria o Level of protein in urine is 500 mg/dl Edema No associated signs and symptoms Management of Mild Preeclampsia Bed Rest o To conserve oxygen o Due to constriction of vessels Limit intake of salty foods o Up to three (3) grams per day Closer follow-up o Weekly check-up Severe Pre-eclampsia Blood Pressure o 160/110 or more Proteinuria Five (5) grams per liter o Measured in twentyfour (24) hour urine output Edema Other signs and symptoms: o Severe headache o Blurring vision due to retention of water going up to optic discs o Fundoscopic examination Looking for papilledema o Pulmonary edema

Crackles Cough Oliguria Urine Output Less than fourhundred milliliters (< 400 ml) in a day Less than thirty thirty milliliters (< 30 ml) in an hour Epigastric pain Aura of an impending seizure Reason for Presence of Epigastric Pain Distention of capsule of liver due to edema Necrosis of pancreas Enzymes release digesting contents of intestine Vomiting Due to increased intracranial pressure (ICP) Pre-

Management of Severe eclampsia Prevention of seizures

PHARMACOLOGIC MANAGEMENT Give Magnesium Sulfate (MgSO4) o Drug of choice o Can also cause decrease in Blood Pressure

46

o (Hydralazine is drug of choice for hypertension) o Check deep tendon reflex o Knee jerk If no reflex, hold magnesium sulfate Hyporeflexia o Magnesium sulfate causes depression o Check Respiratory Rate If less than twelve (12) to fourteen (14) respirations per minute, HOLD Magnesium sulfate causes INCREASED RESPIRATORY DEPRESSION o Check Urine Output Magnesium Sulfate is eliminated through the urine If urine output is low, Magnesium sulfate cannot be eliminated Loading Dose of Magnesium Sulfate Fourteen grams (14 g) Four grams (4 g) via I.V. infusion pump Given for a duration

of thirty (30) minutes This is painful to the blood vessels Ten grams (10 g) via I.M. injection Five grams (5 g) on each buttock / gluteus o Maintenance Dose Give at one to two grams (1 2 g) in one to two hours (1 hr. 2 hrs.) Given via I.V. drip Continue fortyeight (48) hours after delivery Because there is post partum preeclampsia o Antidote Calcium Gluconate One gram (1 g) via direct I.V. OTHER NURSING RESPONSIBILITIES Provide dim light room Limit Visitors Put up side rails Suction machine by bedside Dont put anything in mouth if there is seizure Open collar

47

Turn patient to eliminate saliva Concern is safety

side

to

And USE OF POTASSIUM WASTING FUROSEMIDE

ECLAMPSIA Positive for seizures Give additional medications: o Diuretics Furosemide is the drug of choice o Digitalis (digoxin) To promote contractility of heart without increasing heart rate Inotropic Check pulse rate o In Adults: If pulse rate is less than sixty beats per minute (< 60 BPM) HOLD THE MEDICATION o In children less than ten (10) years old If pulse rate is less than eighty beats per minute (< 80 BPM) HOLD THE MEDICATION In both cases, patient will go into BRADYCARDIA IF MEDICATION IS NOT WITHHELD o Potassium (K+) Prevents DIGITALIS TOXICITY

Important Concepts! Testicular feminization o Result of potassiumsparing diuretics o This is the reason why Lasix is being used Before giving Potassium (K+) o Before I.V. is in the vein, test for backflow o Subcutaneous tissue necrosis o Tissues get burned due to Potassium (K+) Barbiturates Fast acting sedatives To arrest seizure Hydralazine For hypertension HELLP SYNDROME HEMOLYSIS, ELEVATED LIVER ENZYMES, LOW PLATELET Due to necrosis of the liver Disseminated Intravascular Coagulopathy Because of increased pressure in the blood vessels GESTATIONAL DIABETIS MELLITUS Two (2) values elevated in OGTT MANAGEMENT DIET

48

o Maintain daily calorie intake of 1,800 to 2,200 kcal/day o Refrain from eating simple sugars and saturated fats EXERCISE o Appropriate for Age of Gestation PHARMACOLOGIC THERAPY o Insulin Drug of Choice o Oral hypoglycemic agent is teratogenic Important Concepts! Insulin given is based on the weight of the client If client is sixty kilograms (60 kg) o Give 1 / kg / day o Therefore, give sixty units In a B.I.D. dosing o Bigger portion is given in the morning o 2/3 of 60 units = 40 units Smaller portion is given in the evening o 1/3 of 60 units = 20 units Important Concepts! The bigger portion 2/3 portion or 40 units is composed of o Regular Insulin Brief onset For immediate need Thirty (30) minutes to one

(1) hour onset of action Comprises 1/3 of 40 units o Intermediate Insulin For later need Comprises 2/3 of the 40 units Note: The bigger portion is given thirty (30) minutes prior to breakfast Important Concepts! For the smaller portion 1/3 portion or 20 units o 1 : 1 ratio of the regular : intermediate for 20 units 10 units for regular 10 units for intermediate Important Concepts: In drawing insulin Vacuum air First introduced to regular (clear) o Draw this first Then draw on the intermediate type Key Concept! Hypoglycemia causes COMA HEART DISEASE IN PREGNANCY Four (4) Functional Classifications of Heart Disease Class I o Heart Disease is present o But uncompromised Class II

49

o Heart Disease is present o Slightly compromised Class III o Heart Disease is present o Markedly compromised Class IV o Heart Disease is present Severely compromised Important Concepts! If you belong to Class I and Class II o You can go through normal pregnancy If you belong to Class III and Class IV o You cannot go through normal pregnancy o You are not a good candidate In Heart Disease In Pregnancy Labor and delivery should be: Effortless Painless Pushless o A vaginal delivery ANESTHESIA OF CHOICE EPIDURAL ANESTHESIA Upon active labor (3 cm) Check Blood Pressure Side effect is hypotension Important Concepts! No Oxytocin No Methergine No augmentation of labor All natural labor

General Anesthesia only given when crowning occurs o If given early, this crosses the placenta and the effect is a decrease in the APGAR SCORE POSITION OF CHOICE DURING LABOR Will deliver at these positions: Semi-sitting Semi-Fowlers position o Not lithotomy Femoral vessels are obstructed DELIVERY OF CHOICE Outlet forceps extraction Vaginal In Caesarian Section o Normal blood loss is 800 1,000 ml o 1,000 ml blood loss is hemorrhage In Normal Spontaneous Delivery o Normal blood loss is 500 ml o 500 ml blood loss is hemorrhage PUERPERIUM Main Responsibility o Achieve INVOLUTION Return of reproductive organs to prepregnancy state Usually achieved after six (6) weeks PRINCIPLES 1. PROMOTE HEALING Uterus

50

o At level of umbilicus o After the delivery of the placenta One (1) day after o One (1) finger breadth below the umbilicus Two (2) days after o Two (2) finger breadths below the umbilicus Three (3) days after o Three (3) finger breadths below the umbilicus Four (4) days after o Four (4) finger breadths below the umbilicus Five (5) days after o Five (5) finger breadths below the umbilicus Six (6) days after o Six (6) finger breadths below the umbilicus Seven (7) days after o Seven (7) finger breadths below the umbilicus Eight (8) days after o Eight (8) finger breadths below the umbilicus Nine (9) days after o Nine (9) finger breadths below the umbilicus Ten (10) days after o Ten (10) finger breadths below the umbilicus or at the level of the symphysis pubis Eleven (11) days after o Uterus at the pelvic cavity

o If Uterus is midway between the umbilicus and symphysis pubis, this is ABNORMAL This means that there is something left inside SUB-INVOLUTION or POST PARTUM HEMORRHAGE Uterus has not gone back to original size Caused by retained placental fragment LOCHIA Rubra Day one (1) to day three (3) Day two (2) to day three (3) Bright red in color Serosa Day three (3) to day ten (10) Pinkish in color Actually, brown in color Alba Day ten (10) until third (3rd) week up to sixth (6th) week post-partum Important Concept! After six (6) weeks, THERE IS NO MORE LOCHIA CHARACTERISTICS OF NORMAL LOCHIA Normal Odor o Musty but not FOUL SMELLING o Foul smell indicates infection Color

Important Concept! After six (6) weeks, upon Internal Examination. . . 51

o Should not be YELLOWISH o Yellowish color indicates infection Order of Appearance o Should never be reversed o Reversal in appearance indicates RETAINED PLACENTAL FRAGMENTS LACTATIONAL AMENORRHEA Lactating Fully Not ovulating Six (6) months effectivity TO BE EFFECTIVE There must be complete emptying of the breast without supplementation (baby receives no bottle feeding) Four (4) to six (6) months Start Supplementation Important Concepts! Normally, after eight (8) weeks or two (2) months, MENSTRUATION RETURNS If the mother is breastfeeding, it would take six (6) months BEFORE MENSTRUATION RETURNS After three (3) to four (4) weeks, COITUS IS ALLOWABLE 2. PROVIDE SUPPORT EMOTIONAL

Rejecting NORMAL

rooming-in

is

TAKING HOLD After second day o Mother is now independent of self care and newborn care o Time of evidence of POST PARTUM BLUES / DEPRESSION IS OVERT o If poor support system is present, this predisposes to POST PARTUM BLUES / DEPRESSION / PSYCHOSIS o Brief Psychotic episode lasts for three (3) months LETTING GO Completely accepted role as a new mother 3. PREVENTION PARTUM. . . OF POST-

TAKING IN First two (2) days post-partum Mother is very dependent for care for self and the newborn

3.1) MATERNAL HEMORRHAGE Early post-partum hemorrhage Occurs within the first twentyfour (24) hours after delivery Uterine atony is most common cause Lacerations are the second most common cause Inherent clotting disorders occur: o Thrombocytopenia o Leukopenia Late post-partum hemorrhage

52

o Occurs after first twenty-four hours of delivery Common causes: o Primary Cause Retained placental fragment/s o Secondary Cause Hematoma (vaginal) 3.2) INFECTION Endogenous infection Normal flora causes infection These travel up the uterus 3.3) PERINEAL INFECTION On site of episiotomy o Management involves antibiotic therapy Surgical Management o Remove suture o Drain pus Position in Semi-Fowlers position 3.4) ENDOMETRITIS Infection of the lining of the uterus o With maternal fever > 38 C (37.5C is common due to dehydration) o With foul-smelling vaginal discharge With uterine or abdominal tenderness Management for Endometritis Antibiotics Position o Semi-Fowlers position Oxytocin is given o Promotes contractions 53

o Promotes secretion

release

of

Important Concept! ENDOMETRITIS is PRELUDE THROMBOPHLEBITIS

a to

3.5) THROMBOPHLEBITIS Most common site are the vessels of the LOWER EXTREMITIES Positive (+) for HOMANS SIGN How is Homans Sign elicited? o Ask patient to dorsiflex foot o Upon lying supine, legs extended o Stretching of the blood vessels causes pain on calf muscle (gastrocnemius muscle) Management of Thrombophlebitis o Antibiotics o Anticoagulant Heparin Larger molecule than warfarin Less likely to enter breast milk Important Concepts! Discontinue breastfeeding whether heparin or warfarin is administered Antidotes o For Heparin Protamine Sulfate o For Warfarin Vitamin K

ESTABLISHMENT SUCCESSFUL LACTATION La leche Method o When placenta delivered

OF

Day 1 Start breastfeeding for five (5) minutes on each breast Day 2 Provide breastfeeding for six (6) minutes on each breast Day 3 Provide breastfeeding for seven (7) minutes on each breast Day 4 Provide breastfeeding for eight (8) minutes on each breast Day 5 Provide breastfeeding for nine (9) minutes on each breast Day 6 Provide breastfeeding for ten (10) minutes on each breast Stop and maintain ten (10) minute feeding per breast This would give a total of twenty (20) minutes of breastfeeding time Important Concept! Breastfeeding is done on a per demand basis

is

o There is decreased estrogen and progesterone o This indicates production of PROLACTIN o Stimulation of acinar cells to produce milk and stored in the lobules o Upon OXYTOCIN RELEASED sucking, IS

This is the hormone responsible for the EJECTION OF MILK

HOW TO BREASTFEED Offer entire breast up to the areola Assume side lying position Hype up to suck whole nipple and areola Pull breast tissue away from the NOSE of the baby

54

COMPARISON OF BREAST MILK AND COWS MILK


PROTEIN CONTENT BREASTMILK Less COWS MILK Greater protein content; Casein causes curdling of milk; Difficult to digest Therefore, baby tends to be constipated; Water is supplemented Decreased

o Mark coitus schedule o Mark time of menstruation Important Concepts!!! Progesterone CAUSES INCREASE IN TEMPERATURE Estrogen CAUSES DROP IN TEMPERATURE Peaking of Estrogen Results in SLIGHT DROP of SLIGHT DECREASE IN TEMPERATURE Temperature goes down by C Upon Leutinizing Hormone (LH) surge (this is the EXPECTED TIME OF OVULATION), there is INCREASE IN PROGESTERONE o Immediate increase in temperature (coincides with LH surge and increase in progesterone) o Temperature increases by 0.3C to 0.4C and WILL HAVE PLATEAU FOR THREE (3) DAYS THIS SIGNALS HIGH AMOUNT OF PROGESTERONE As progesterone level decreases, the temperature goes down THEREFORE, DO NOT ENGAGE IN COITUS FROM THE DECREASE IN TEMPERATURE UP TO THE END OF THE PLATEAU From then on, up to menstruation this period is 55

CARBOHYDRATE CONTENT

FAT CONTENT

VITAMINS MINERALS

AND

Greater Carbohydrate Content; Most easily digestible form of carbohydrate Equal 50% Has EFA (esterified fatty acid) Has four times more EFA (essential fatty acid) than cows milk; Linoleic fatty acid is for brain growth Calcium is low Four times less than in Cows milk

Equal 50%

Increased; Four times more calcium than in breastmilk; Detrimental to kidneys of newborn; Excretion of solute is hampered due to immaturity

FAMILY PLANNING NATURAL METHODS 1. RHYTHM 2. BASAL BODY TEMPERATURE Observe temperature for six (6) months or more Taken per mouth or per axilla Take temperature upon waking up Graph FAMILY PLANNING

considered PERIOD

the

SAFE

PILLS Usually taken at night When you forget to take one (1) pill o Take the pill that you forgot the time that you remembered you forgot to take it o Take pill scheduled for that day When you forget to take two (2) pills (example: for Friday and Saturday and today is Sunday) o Take two (2) pills now (for Friday and Saturday) o Take two again tomorrow (Monday) o This will cover the pill requirements for Sunday and Monday o Then next day resume taking following the regular schedule (Tuesday) If you forget to take your pills for three days. . . o Discard o Wait for withdrawal bleeding or menses o Start with new set of pills Nauseated with pills INTRAUTERINE DEVICE Best time for insertion o During the second (2nd) day of menses o You know you are not pregnant Cervix is slightly open

ABSOLUTE CONTRAINDICATION o When you have abnormal uterine bleeding o Nulliparous o History of Pelvic Inflammatory Disease o History of Sexually Transmitted Disease TUBAL LIGATION Best time o Post-partum Within four (4) to six (6) hours after delivery o Or during interval Tubal Ligation Discharge Advice patient to come back after some time Coitus protected prior to procedure (condom) Do not engage in coitus three (3) days before the procedure It is permanent o Failure rate for recannalization is high o Therefore, do not push through with tubal ligation if mother does not accept that it is permanent Restrict lifting of objects heavier than newborn Coitus Two (2) to three (3) days after the procedure In Bilateral Tubal Ligation (BTL), there is IMMEDIATE STERILITY o Resumption of all other activities (in BTL) after 56

six (6) weeks to prevent DEHISCENCE VASECTOMY Does not give immediate sterility o There is a waiting time of six (6) months o Sperm is still stored After six months, patient can engage in unprotected coitus Vas deferens is cut Not popular among Filipinos SYSTEMIC CHANGES PREGNANCY DURING

SYSTOLIC (all pathologic) in nature o Innocent in nature o As soon as mother delivers placenta, excess fluid is absorbed or excreted, then the MURMUR DISAPPEARS Blood Volume is INCREASED due to INCREASE IN WATER RETENTION HIGHEST CARDIAC OUTPUT IN PREGNANCY Twenty-eight to thirty-two weeks (28-32 wks) Age of Gestation During labor and delivery Immediately postpartum Therefore, be careful and monitor pregnant cardiac patient Supine Hypotensive Syndrome o When mother assumes supine position, she develops hypotension o Weight of uterus presses on the VENA CAVA This results into DECREASED VENOUS RETURN This results into DECREASED CARDIAC OUTPUT End result is HYPOTENSION Therefore, SUPINE POSITION IN PREGNANCY IS NOT ALLOWABLE

1. CARDIOVASCULAR SYSTEM HEART As diaphragm rises, the heart is displaced laterally Point of Maximum Impulse o Normally located at Fifth Intercostal Space Mid-clavicular Line on the Left Side {5th ICSMCL (L)} o This shifts to Fourth Intercostal Space Lateral Axillary Line on the Left Side {4th ICSLAL (L)} Exaggeration of first and second heart sounds {S1 (Lub) and S2 (Dub)} due to INCREASED CARDIAC OUTPUT Appreciation of S3 (third heart sound; ventricular filling) due to INCREASED CARDIAC OUTPUT Appreciation of a MURMUR, which is almost always

57

(particularly in the second and third trimester) POSITION OF CHOICE o Side-lying Left (so as not to impede the Vena Cava o Left Lateral Position o Sims Left Position With arm flexed Leg flexed Weight of uterus would be ON THE BED 2. HEMATOLOGIC CHANGES HEMODILUTION Due to increase in PLASMA VOLUME CHANGES IN PLATELET Expected during Postpartum Due to blood loss, there is TRANSIENT INCREASE IN PLATELET COUNT This predisposes to THROMBOSIS due to platelet aggregation This would then predispose to EMBOLISM Therefore, EARLY AMBULATION is NEEDED Important Concept! WHITE BLOOD CELL LEVELS INCREASE (particularly in labor) LEUKOCYTOSIS is STRESSINDUCED o Increased by 20K to 30K

Therefore, DO NOT CORRELATE THIS TO INFECTION NO FEVER NO abdominal / uterine infection 3. RESPIRATORY SYSTEM Diaphragm is prevented from descending in inspiration on second and third trimester Tidal Volume is increased o Lungs are easily filled o Client tends to hyperventilate o Therefore, RESPIRATORY ALKALOSIS OCCURS This is manifested by: o Tingling sensation on the lower ends of extremities o Lightheadedness Nursing Management o Breathe through a paper bag or through cupped hands Important Concepts! During labor, there is increase in oxygen consumption by three-hundred percent (300%) o When exhaling, pursed lip breathing is practiced during labor Swelling of mucosa during estrogen o Prone to epistaxis o Therefore, caution in picking nose! 4. GASTROINTESTINAL TRACT 4.1) PICA Craving for food 58

Unedible (i.e. rice grains) No reason for this May be due to hypersalivation If not checked, this causes vomiting

Nursing Management Do not assume supine position after eating Gradual ambulation Small Frequent feeding

4.2) EPULIS OF PREGNANCY Effect on gums Swelling of gums due to INCREASED ESTROGEN Therefore, CONTINUE TO USE SOFT BRISTLE TOOTHBRUSH 4.3) ESOPHAGUS Progesterone is a relaxant of smooth muscle o Effect is on lower esophageal sphincter o It is more relaxed Pressure of Lower Esophageal Sphincter (LES) is less than pressure on Cardiac Sphincter (CS) o If LES pressure is > CS pressure No regurgitation o If LES pressure is < CS pressure o There is HEARTBURN OR PYROSIS; SUBSTERNAL PAIN related to eating Interjected Concept! Most common surgical complication of pregnancy is ACUTE APPENDICITIS! Right Upper Quadrant pain is not expressed during pregnancy or on flank as the appendix rises in pregnancy

Important Concepts! Due Progesterones relaxing effect on smooth muscles, there IS INCREASED GASTRIC EMPTYING TIME o Water and electrolytes absorbed by walls o This gives rise to hard stools o This eventually leads to constipation Management o Increase fluid intake o Provide high fiber diet Tendency is to do valsalva maneuver o This leads to hemorrhoids Progesterone also decreases stretchability of vessels. o This also causes hemorrhoids 5. RENAL SYSTEM OR EXCRETORY

5.1) Due to Progesterone There is relaxation of renal pelvis and the ureter Therefore, URINE STAGNATION occurs in the URETER (no longer peristaltic) Therefore, the PATIENT IS PRONE TO URINARY TRACT INFECTION

59

5.2) Glomerular Filtration Rate in Pregnancy Increased Cardiac Output Increased Glomerular Filtration Rate But absorptive capacity of nephrons is not increased (NO CHANGE IN ABSORPTION) Therefore, the following will be spilled in the urine: o Sugar o Carbohydrates o Protein Important Concepts! Carbohydrates in the urine is NORMAL Acceptable level of Carbohydrates in the urine o Qualitative analysis o Trace = +1 sugar Protein in the urine is NORMAL Acceptable level of Proteins in the urine o Trace = +1 Protein o Or less than 250 mg / dl If Protein level in the urine is greater than 250 mg / dl, CONSIDER PREGNANCY INDUCED HYPERTENSION Important Concepts! If you LOSE PROTEIN and RETAIN WATER, this leads to EDEMA o This is Physiologic Edema o This type of edema is normal and expected in pregnancy
TYPE OF EDEMA PHYSIOLOGIC PATHOLOGIC

LOCATION OF EDEMA TIME OF OCCURRENCE

Dependent portion of the body; leg or lower extremity Afternoon or PM

Independent portion; Upper extremities, face, arms Althroughout the day but evident in the morning Ring cannot be removed

Important Concepts! No management for PHYSIOLOGIC EDEMA o Supportive o Leg raises For Pathologic Edema o Identify the cause of the edema o Most common cause is PREGNANCY INDUCED HYPERTENSION 6. ENDOCRINE SYSTEM Hypertrophy is present in most of the endocrine system organs Thyroid Gland is hyperthrophied Increased production of thyroid hormones Therefore, there is RISK FOR HYPERTHYROIDISM o Patient may die when in labor with hyperthyroidism o Thyroid Storm leads to arrhythmia o Arrhythmia leads to DEATH Therefore, monitor so that client goes EUTHYROID (with normal thyroid hormonal level)

60

7. NEUROLOGIC SYSTEM This is the only system UNAFFECTED during pregnancy The following are normal during pregnancy: o Blurring of vision Headache

FETAL CIRCULATION PLACENTA Functions of the Placenta Mnemonic is NIMEE N is for: NUTRITION or NIDATION o Supplying nutritional requirements of the fetus o Nutrients and oxygen exchanged o THE BLOOD IS NOT EXCHANGED o Modes of Exchange Active transport from mother to baby Diffusion Pinocytosis I is for: IMMUNOLOGIC o If not pregnant, all foreign matter antigens are rejected o Baby is a foreign matter o But immunologic function of the placenta removes the MAJOR HISTOCOMPANITIBILI TY COMPLEX TYPE 2 (MHC TYPE 2) o This is responsible for rejecting the foreign body M is for: METABOLIC FUNCTION o In Fetal Circulation

8. MUSCULOSKELETAL SYSTEM 8.1) PLACENTA IS CAPABLE OF PRODUCING RELAXIN Relaxes pelvic joints Therefore, the pelvis is more movable 8.2) DIASTASIS RECTI Separation of rectus abdominis muscle Only fascia remains in between This is normal Rectus abdominis muscle goes back after pregnancy (coarctate) 8.3) PHYSIOLOGIC LORDOSIS Known as the PRIDE OF PREGNANCY Increased outward curvature o There is back pain Nursing Management o Do PELVIC ROCKING Place direct pressure on lumbar area o Prevent supine position Increases pressure on the spine o No analgesics

61

Nutrient exchange occurs NO PORTAL CIRCULATION EXISTS Liver is bypassed as METABOLISM (by the liver) is NOT NEEDED

E is for: ENDOCRINOLOGIC o Hormones are secreted only during pregnancy: Human Placental Lactogen Human Chorionic Gonadotropin Relaxin E is for: EXCRETORY Metabolites excreted by Placenta and NOT BY THE KIDNEY NOR THE LIVER FETAL CIRCULATION Starts from the placenta Connected to the uterus Decidua is bathed UTERINE ARTERY

by

Uterine Artery Sinuses of the Placenta Exchange of nutrients Umbilical vein Placenta

Umbilical vein (composed of two arteries and one vein AVA) Liver Ductus Venosus (First Shunt) Inferior Vena Cava Right Atrium Foramen Ovale (Second Shunt) Left Atrium Left Ventricle Aorta To upper half of the fetal body only Upper Extreme Brain Heart Pulmonary Upper part of the GUT Then this blood is recollected with less oxygen and then it goes to the Superior Vena Cava Right Atrium Right Ventricle Pulmonary Artery (but lungs are collapsed; Surfactant inadequate and amniotic fluid is present) Ductus Arteriosus Descending Aorta

62

Supply the lower half of the fetal body Blood is recollected Hypogastric Artery Umbilical Artery Placenta Question: In the fetal circulation, which part has the higher pressure? Answer: Right Side Important Concepts!!! There is ONE-WAY flow of blood from the RIGHT ATRIUM to the LEFT ATRIUM Therefore, Right AtriumPressure > Left AtriumPressure SHUNTS When the baby is delivered, the shunts are normally removed o Ductus Venosus o Foramen ovale Two (2) types of Closure Functional Closure Anatomic Closure FORAMEN OVALE Closed functionally immediately after birth or IMMEDIATELY AFTER CORD IS CLAMPED Anatomically, it can persist up to one (1) year after delivery Important Concept!

o Therefore, in auscultation in twentyeight (28) day old baby There is a MURMUR This is Normal This is NOT A PATHOLOGIC MURMUR It is a SYSTEMIC / INNOCENT MURMUR o A PHYSIOLOGIC MURMUR IN NEONATES DUCTUS ARTERIOSUS Functional Closure o Ten to ninety-six hours (10 96 hrs) after birth or approximately four (4) days Anatomically o Two to three months (2 3 mos.) DRUGS TAKEN PREGNANCY DURING

NSAIDs Indomethacin o Not advisable o Causes premature closure of the Ductus Arteriosus o Not compatible with life o No supply to the lower half of the body of the fetus PARACETAMOL IS ALLOWED

63

ASPIRIN Causes persistence of Ductus Arteriosus even after delivery No functional / anatomic delivery of Ductus Arteriosus Important Concept! o Stop taking about four (4) weeks prior to confinement Interjected Concepts! o EDC Expected Date of Confinement o EDD Expected Date of Delivery

ASSESSMENT OF FETAL MATURITY AND WELL-BEING 1. MATERNAL HISTORY PHYSICAL EXAMINATION AND

1.1) First thing to ask is the LAST MENSTRUAL PERIOD Purpose is to IDENTIFY THE AGE OF GESTATION 1.2) What are History of Previous Pregnancy: NSAID? Postpartum complication? Infection? 1.3) Past Medical History Diabetes Mellitus? Gestational Diabetes? Hypertension? 2. FETAL HEART TONE Easiest method to assess for fetal well-being

Very reliable indicator of oxygenation of the fetus If FHT is heard o Fetus is alive o THIS IS AN ALL OR NONE RESPONSE NORMAL o 120 160 beats per minute If greater than 160 o Tachycardia If less than 120 o Bradycardia Be able to assess that sound you hear in the mother is the FHT In the mothers abdomen, you can hear: o BORBORYGMIC SOUNDS Hunger sounds o UMBILICAL SOUFFLE When the blood in the placenta enters the umbilical vein, this coincides with the Fetal Heart Tone But FHT should be DISTINCT Fetal Heart Tone sound TUG TUG TUG Umbilical Souffle Sound SHHH SHHH SHHH This is the sound of the

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gush of blood o UTERINE SOUFFLE Sound heard when blood enters uterine artery This coincides with the heartbeat of the mother IDEAL WAY TO TAKE THE FETAL HEART TONE Use the bell of the stethoscope o Purpose is for greater amplification Hand / Dominant Hand o On area being auscultated Non-Dominant Hand o Palpates radial pulses for the mother Therefore, you can correlate o FETAL HEART TONE IS DISTINCT TUG TUG TUG TUG o Radial pulse of the Mother is Tug - - - - - - Tug - - - - - - Tug FETAL MOVEMENT Two (2) schools of thought o Cardiff Count to Ten o Sandovsky Method CARDIFF COUNT TO TEN Normal Fetal Movement o At least one (1) movement every five (5) to six (6) minutes

o About ten (10) to twelve (12) movements per hour First Instruction o Instruct the client to eat LIGHT MEAL one (1) hour before monitoring for fetal movement Have short walk or massage abdomen as baby may be asleep or is hungry Ask mother to assume left lateral position A clock must be at the bedside with pencil and paper Dominant hand of mother palpates most prominent part of abdomen Note for any fetal movement FETAL MOVEMENT SHOULD BE ASSESSED WHEN THERE IS QUICKENING (AT TWENTYFOUR MONTHS AGE OF GESTATION ONWARDS) Mother notes for ten (10) fetal movements and NOTES THE TIME THAT THE TEN (10) FETAL MOVEMENTS HAVE BEEN COMPLETED o Should be completed in one (1) hour o Approximately five (5) movements in thirty (30) minutes You MUST get at LEAST ONE HALF OF NORMAL Therefore, AT LEAST FIVE (5) FETAL MOVEMENTS PER HOUR IS ACCEPTABLE of

Important Concepts! Approximate number growing follicles:

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o At twenty-eight (28) weeks Age of Gestation 6,000,000 o At Term 1,000,000 o At menarche 400,000 o At forty (40) years of age 8,000 SANDOVSKY METHOD Same procedure as in Cardiff Count to Ten Mother monitors fetal movement three (3) times a day These are done: o After breakfast o After lunch o After dinner Normal You should appreciate two (2) to three (3) fetal movements in one hour OTHER WAYS DIAGNOSTICS TO ASSESS:

L : S Ratio o Lecithin : Sphingomyelin Ratio Lecithin is a specific component of lung surfactant o Lecithin should be greater than Spinglomyelin o Normal Ratio is 2L : 1S If there is anticipated premature delivery, amniocentesis is done to know if delivery is viable PHOSPHATIDYL GLYCEROL (PG) Most potent of all lung surfactants Usually appreciated at amniotic fluid at THIRTYFOUR to THIRTY SIX (34 36) WEEKS AGE OF GESTATION Therefore, it is safe to deliver fetus if Phosphatidyl Glycerol is present There is decreased risk of respiratory distress POLYHYDRAMNIOS Amniotic fluid greater than 2,000 ml o A teratogenic effect Therefore, remove part of amniotic fluid IDENTIFICATION OF GENETIC OR CHROMOSOMAL PROBLEM HOW TO PREPARE THE CLIENT FOR AMNIOCENTESIS Explain what to do to the client Get Consent

AMNIOCENTESIS Best done at sixteen to eighteen (16 18) weeks Age of Gestation or during second (2nd) trimester This is the time when the baby is SMALL and there is MUCH AMNIOTIC FLUID Information Obtained: A) FETAL LUNG MATURITY Analyzed for lung surfactant: Dipalmytoyl Phosphatidylcholine 66

Remember, CONSENT IS NEEDED as this procedure is INVASIVE! Client must have I. V. fluid o Plain Normal Saline Solution o Side drip of Tocolytic to relax the uterus Ask client to void before the procedure so as not to puncture bladder o Ultrasound-guided procedure o Needle should not puncture the placenta Abdomen is prepared aseptically Specific Site o Pocket of abdomen containing highest amount of Amniotic Fluid o Done by OBSTETRIC SONOLOGIST Needle Inserted o Local anesthesia o Abdominal wall through the uterus to amniotic sac Post Procedure o Check Vital Signs (every fifteen (15) minutes) o Check Blood Pressure o Check Fetal Heart Tone o Client then rests for two (2) to three (3) hours o Mother is then sent home DISCHARGE INSTRUCTIONS

o Note for UTERINE TONE o Note for Fetal Activity o Client may be: Hyperactive In distress Hypoactive In distress o Note for vaginal bleeding or spotting o Vaginal spotting is acceptable DANGER SIGNS Persistent uterine contraction Hyper / Hypoactive Vaginal Spotting to Bleeding o Therefore, ask mother to come back if she observes any of the above signs MATERNAL SERUM ALPHA FETOPROTEIN A special kind of protein produced in the yolk sac of the liver of baby / fetus Specimen is blood Consent is needed Normal value of Maternal Serum Alpha Feto Protein (MS AFP) o 2.0 2.5 MOM (measurements of the mean) If MS AFP is higher than normal, THERE IS A NEURAL TUBE DEFECT: o Spina bifida o Meningocoel o Myelomeningocoel o Anencephaly

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If MS AFP is lower than normal, THERE IS DOWNS SYNDROME Therefore, you must be able to know exact Age of Gestation Fifteen to Twenty (15 20) weeks Age of Gestation is the IDEAL TIME FOR MS AFP or during the SECOND (2nd) TRIMESTER, not on the First or the Third Trimesters If early high result o Yolk sac and liver gives false elevated result If late low result o Liver only gives false low result CHORIONIC VILLUS SAMPLING (CVS) Get part of chorionic villi from the placenta Done at nine to twelve (9 12) weeks Age of Gestation Approach is INTRAVAGINAL Ultrasound-guided A part of chorionic villi near maternal attachment will be suctioned to the catheter for KARYOTYPING and GENETIC ANALYSIS Purpose of this procedure is for detection of genetic and chromosomal problems Nursing Responsibility o Bleeding is common in CVS o Instruct mother to observe SPOTTING to BLEEDING o Ask mother to come back if bleeding occurs

Therefore, not much done; increases chance of abortion or fetal loss PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS) Also known as CORDOCENTESIS Get sample Ultrasound-guided Sonologist identifies umbilical vein o Vein has larger lumen than the artery Catheter is inserted Approach is through the abdomen Information obtained: o For identification of blood incompatibilities o For exchange transfusion o For isoimmunization Needed in instances of an Rh+ baby and an Rh- mother ULTRASOUND Types of Ultrasound Transabdominal Ultrasound Transvaginal Ultrasound

TRANSABDOMINAL ULTRASOUND Ask the client to FILL BLADDER Full bladder will push uterus to pelvic cavity for better visualization at abdomen ULTRASOUND TRIMESTER IN FIRST

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Information obtained: Confirmation of Pregnancy o (+) cardiac movement o (+) yolk sac o (+) Fetal Heart Tone Identification of Ectopic Pregnancy o Fallopian tube is PERISTALTIC o Therefore, look at the uterus o If the uterus is empty and positive (+) for pregnancy test, then there is pregnancy outside or ECTOPIC PREGNANCY Identification of Intrauterine Device (IUD) in Place o Intrauterine Device Has 97% protection Has 3% failure rate o If IUD is in place and pregnancy occurs, advice the client to LET THE IUD STAY IN PLACE o IUD will attach to the fetal membrane o If taken out, there is greater chance of SPONTANEOUS ABORTION Identification of the H-MOLE o Ultrasound characteristic of H-Mole SNOW STORM APPEARANCE In a dark background there is a speck of white 69

There vesicles with fluid

are filled

ULTRASOUND IN THE SECOND AND THIRD TRIMESTER Information obtained: Location of Placenta o Placental Localization Growth of the Fetus Amount of Amniotic Fluid Fetal Position and Fetal Presentation Sex / Gender of the baby o Determinable at sixteen (16) weeks of gestation o Ideal time is twentyeight (28) weeks Congenital / Chromosomal Problems o Determined by threedimensional (3D) ultrasound TRANSVAGINAL ULTRASOUND Ask client to void BIOPHYSICAL SCORE Has five (5) parameters (including Non-Stress Test or NST) Modified Biophysical Score o Has four parameters only Uses ULTRASOUND Criteria / Parameters observed o Fetal Breathing Two (2) is the highest score for this parameter o Fetal Movement Two (2) is the highest score for this parameter

o Fetal Muscle Tone Flexion and extension in utero Two (2) is the highest score for this parameter o Amniotic Fluid Index Done for a period of thirty (30) minutes Babys breathing is not spontaneous Two (2) is the highest score for this parameter Perfect score is 8/8 o This means that the baby is in the best possible health Before, Biophysical Score includes the Non-Stress Test Non-Stress Test o For fetal heart activity o With this parameter added, the perfect score in BPS becomes 10/10 NON-STRESS TEST Uses CARDIOTOGORAPH (CTG) TRACING No stressor on part of the baby Stressor is the contraction of the uterus There should be NO CONTRACTION Compare o Fetal Heart Tone and Fetal Movement If baby moves, FHT INCREASES! 70

With two (2) transducers placed near FHT at fundus of uterus Leopolds maneuver Water soluble lubricant o KY jelly amplifies FHT TOCO o No lubricant at fundus of uterus So that it is verified There is no contraction FHT 150 140 BASELINE130 120 110 100
FLAT LINE (NO CONTRACTION)

UC
(MEASURED IN PRESSURE)

Push button o If mother feels fetal movement CRITERIA TO SAY NST IS NORMAL Period of Observation should be o Greater than or equal to twenty (20) minutes You must get at least two (2) accelerations in twenty (20) minutes Acceleration should be at least fifteen (15) beats above baseline Duration of acceleration should be

o Greater than or equal to fifteen (15) seconds o One (1) small square = one (1) second Therefore, IF ALL CRITERIA ARE MET, NON-STRESS TEST IS NORMAL KEY CONCEPT!!! If NST is NORMAL IT IS REACTIVE Therefore, the chances of fetal survival is greater than 99% in the next week You can assure the mother If NOT ALL CRITERIA ARE MET (i.e. Criteria No.3 with 10 beats per minute only), Repeat NST after two (2) to three (3) hours FHT 150 140 BASELINE130 120 110 100

Then, proceed with Contraction Stress Test If CST could not be withstood by baby, IT NEEDS IMMEDIATE DELIVERY Introduce a STRESSOR CONTRACTION if ABNORMAL CST OXYTOCIN CHALLENGE TEST Rub nipples o Nipple stimulation if uterus is NOT contracting When assessing o Hide your thumb o If you are a male so as not to be sued for sexual harassment NIPPLE STIMULATION o Give warm pack / warm soaks for ten (10) minutes prior to stimulation to increase circulation / vascularity o Explain procedure o Start o Four (4) cycles per stimulation o 1, 2, 3, 4 stimulations REST x4 First Cycle o If after these and there are NO CONTRACTIONS o Stop and rest for two (2) to four (4) minutes o Then stimulate o Up to four (4) cycles If NO CONTRACTIONS AFTER THE FOURTH (4th) CYCLE o Stop stimulation o Proceed with Oxytocin Challenge Test 71

UC
(MEASURED IN PRESSURE)

Important Concept! If NST is NON-REACTIVE, it is ABNORMAL CONTRACTION STRESS TEST (CST) Best done when mother is at thirty-eight (38) weeks Age of Gestation Done when NST is NONREACTIVE

OXYTOCIN CHALLENGE TEST Give diluted form of oxytocin o Five units (5U) or ampule + 1 liter D5LR or D5H2O Give at a titrating dose Start at ten to twelve (10-12) drops per minute to a maximum of forty (40) drops per minute Observe for Uterine Contraction Wait for two (2) consecutive uterine contractions Stop Oxytocin Challenge Test if two (2) uterine contractions are obtained Now compare Uterine Contractions with Fetal Heart Tone FHT 150 140 BASELINE130 120 110 100 UC

o Bradycardia o Hypotension Important Concept! Abnormal if POSITIVE (+) FOR DECELERATION FHT 150 140 BASELINE130 120 110 CST IS ABNORMAL 100 UC Note for timing of deceleration in relationship to contraction o Deceleration is before contraction o Shape of deceleration is U-SHAPED o Deceleration has early recovery to baseline level Important Concepts! If (1), (2) and (3) above are present, it is called EARLY DECELERATION o The most NORMAL of all the ABNORMAL If mother is in TRANSITIONAL PHASE o Cervix is 8 10 cm dilated o Head / presenting part in vaginal vault In the dura of the brain is the innervation of the vagus nerve If head of baby is in the pelvis If vagus nerve is stimulated, there is BRADYCARDIA If head is released, there is normalization 72

CST IS NORMAL OR NEGATIVE

NEGATIVE o In the presence of uterine contraction, tracing is NEGATIVE FOR DECELERATION Vagus Nerve o Parasympathetic Stimulation gives rise to bradycardia Carotid Stimulation results into

Therefore, EARLY DECELERATION is NOT PRESENT in the EARLY STAGE of the FIRST STAGE of LABOR If NORMAL, DO NOTHING!!!! o JUST OBSERVE o This is NORMAL! Second type of Deceleration FHT 150 140 130 BASELINE120 110 100 UC Deceleration o Occurs anytime (variable) during contraction o W-shaped Deceleration o Decrease in baseline from 130 to 125 Therefore, TYPICAL VARIABLE DECELERATION Significance: o Signifies CORD COMPRESSION but not necessarily Cord Prolapse o Therefore, INTERVENE IF THERE IS CORD COMPRESSION INTERVENTIONS If in labor: Turn client position

Stop oxytocin immediately o No contractions are wanted Give oxygen to mother o Rate is 8 10 liters per minute Hydrate with plain water o No incorporation of oxytocin to increase circulating blood volume o Mother is on NPO during labor and there could be DEHYDRATION ADH secretion is increased to conserve water o ADH is released from the posterior pituitary o Oxytocin is released from the posterior pituitary o Cross reaction of ADH and Oxytocin in the Uterus o ADH binds in OXYTOCIN RECEPTORS in Uterus resulting to CONTRACTION o Therefore, hydrate so as not to increase ADH secretion If variable deceleration is >10 minutes, then CAESARIAN SECTION may be NECESSARY Third Type of Deceleration

to

left

lateral

FHT

150 140 BASELINE130 73

120 110 100 UC LATE DECELERATION Occurs before contraction ends Has a late recovery Baseline is changed Lower than original baseline Significance: o UTEROPLACENTAL INSUFFICIENCY is present Management o Hydrate o Give oxygen o Stop oxytocin Placenta and Uterus are compromised o Therefore, this is an indication for OUTRIGHT ABDOMINAL DELIVERY o Do outright Caesarian Section PRE-NATAL ASSESSMENT In the Ideal Setting: At zero to twenty-eight weeks (0 28) Age of Gestation o Ask client to come back every four (4) weeks At twenty-eight to thirty-six weeks (28 36) Age of Gestation o Ask client to come back every two (2) weeks At thirty-six (36) weeks onwards 74

Ask client to come back every week DOH RECOMMENDATION One (1) pre-natal check-up per TRIMESTER Three (3) pre-natal check-ups during the entire course of pregnancy If high risk Below 18 years old Above 35 years old Greater than Gravida 5 o Due to higher chances of maternal bleeding after delivery Problem in placentation (location) History of Maternal illness o Hypertension o Diabetes mellitus o Cardiac Problems Clinical check-up should be performed every week! Important Concepts! Auscultate the lungs on the first visit Nursing history has physical examination o This is done by the nurses o Not weigh o Baby is sleeping contentedly o Baby will cry Changes in heart rate NO IPPA IN PEDIATRIC PATIENTS Get Maternal History of Client Laboratory Examinations

COMPLETE BLOOD COUNT Hemoglobin Hematocrit Platelet Rh and ABO blood typing Important Concepts! Asians NOT COMMONLY Rh Caucasians are COMMONLY RhBLOOD NOMENCLATURE ABO Typing o Type A, B, O o A or B antigens Rh Typing o Rh (C, D, E) o Three antigens C D E o In incompatibility, the concern is the D antigen Rh Mother is RhFather is Rh+ No D antigens Rh or Rh0 (zero for D) Baby is Rh+ or Rh(D) Antigen D is present in the blood Important Concept! The first pregnancy is spared The first baby is born Blood enters mothers circulation Therefore, mother PRODUCES ANTI-D antibody

Interaction During time of delivery when the placenta starts to detach from maternal attachment Abortion / Dilatation and Curettage Some fragments of placenta are retained in the uterus Ancillary Procedures like AMNIOCENTESIS Interaction of blood of baby entering mother occurs and stimulates antigen-antibody reaction Second Pregnancy Anti-D antibody of mother hemolyzes the Antigen D of second baby o This results into erythroblastosis fetalis or death of the RED BLOOD CELLS o Second baby would have SEVERE ANEMIA HEART FAILURE ANASARCOUSDE ATH RHOGAM Gamma globulin A pre-formed antibody Given within seventy-two (72) hours If to undergo amniocentesis o Rhogam is given before the procedure If mother undergoes abortion o Rhogam is given within seventy-two (72) hours after abortion If pregnant now

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o Give at twenty-eight to thirty-two (28 32) weeks Age of Gestation o to Rhmother REGARDLESS OF Rh of Baby Important Concept! Rhogam is repeated prior to term at forty (40) weeks Rhogam has a half life Rhogam may be out of circulation COOMBS TEST Two (2) types Direct Coombs Test Indirect Coombs Test DIRECT COOMBS TEST Concerns the Baby PUBS Identify if RBC of baby has hemolysis and has attached antibody Therefore, sensitization has occurred on the mother INDIRECT COOMBS TEST Concerns the mother Identify for titer of antibody o Get blood sample o Identify titer of Anti-D o Zero titer if Rh+ o If Rh- individual 1 : 8 or 1 : 16 If titer is less than 1 : 8 this means that MOTHER IS NOT YET SENSITIZED o Therefore, blood of the mother is FREE OF ANTI-D antibody o There is a need for Rhogam 76

If titer is greater than 1 : 16 this means that there is SENSITIZATION o It has ANTI-D antibody o Then, Rhogam is NOT needed o Rhogam CANNOT REVERSE SENSITIZATION Interjected Concepts G3P2 Cervix is 9 cm dilated EEFM TWO (2) ABSOLUTE CONTRAINDICATIONS FOR CONTRACTION STRESS TEST If client is premature (Biophysical Score is used instead) History of problem in the placenta (placentation) Situation Mother is Type O Rh Baby is Type A Rh+ Question What type of blood do you give? Answer Give type A blood Rationale Hemolysis is present Baby has anti-D that is why there is hemolysis If Rh+ is given o There is continuous antibody given there is confirmed hemolysis o Therefore, give Rh-

KEY CONCEPT! ALWAYS GIVE THE BLOOD TYPE OF THE MOTHER (as far as Rh is concerned) Important Concept! If mother is Rh+ and father is Rh+, then the baby is Rh+ and there is no problem ABO BLOOD GROUPS Blood Antigen Type A A B B AB A and B O None Antibody Anti-B Anti-A None Anti-A and Anti-B

If greater than 15 mg / dl, transformation is needed ABO INCOMPATIBILITY is protective against Rh INCOMPATIBILITY o If Mother is type O o If Baby is type A RBC carries Rh(D) o RBC of baby contains D antigen o Since hemolysis has already occurred, AntiD of mother will no longer hemolyze any RBC with Anti-D URINALYSIS Note for infection White Blood Cells o Pus Cells o Common minute amount of pus cells o Normal Value is 5 / hpf (high power field) o In Females 5 / hpf means there is INFECTION < 5 / hpf means NO INFECTION o In males 5 / hpf is SIGNIFICANT URINE SAMPLES Wash perineum Dry perineum Let first stream pass out o This is done to flush bacteria outside urethra Get midstream void Given sterile container with pack with iodine

Important Concepts! Type O blood causes hemolysis If baby is type A, B, AB Question What type of blood in mother will cause hemolysis in ABO? Answer Type O Question What type of blood will be given to the baby if there is ABO incompatibility? Answer Blood type of mother Important Concepts! Most common cause of PATHOLOGIC JAUNDICE is ABO INCOMPATIBILITY Pathologic Jaundice is prolonged jaundice Normal Value of Bilirubin o 15 mg / dl

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GLUCOSE CONTENT OF BLOOD Glomerular Filtration Rate is increased Normal to see trace and +1 Glucose Normal to see trace and +1 protein or < 250 mg / dl GLUCOSE TESTING IN BLOOD Screening Procedure GLUCOSE CHALLENGE TEST For diagnosis of GESTATIONAL DIABETES MELLITUS Best timing is twenty-four to twenty-eight (24 28) weeks Age of Gestation This is the PEAK PERIOD FOR INSULIN RESISTANCE No need for fasting Give mother concentrated glucose solution (orange juice) o 50 grams per orem Wait for one (1) hour Blood sample is drawn from the mother Two (2) probable results: o Glucose level < 140 mg / dl Normal Therefore, STOP There is remote risk of GESTATIONAL DIABETES MELLITUS o Glucose level > 140 mg / dl Abnormal There are chances of developing GESTATIONAL 78

DIABETES MELLITUS Therefore, PROCEED WITH ORAL GLUCOSE TOLERANCE TEST ORAL GLUCOSE TOLERANCE TEST (OGTT) Fasting is needed for 8 10 hours or 8 12 hours Example: o NPO by 12 midnight o Be at clinic by 8:00 AM Draw specimen for Fasting Blood Sugar (FBS) Give concentrated glucose solution o 100 grams per orem Wait for one (1) hour Draw blood sample Wait for another hour Draw another blood sample Wait for another hour Draw another blood sample o Therefore, four (4) drawings of blood 1 FBS Normal <95 mg/dl 2 1st Hour Normal <180 mg/dl 3 2nd Hour Normal <155 mg/dl 4 3rd Hour Normal <140 mg/dl

Important Concept! If client has TWO VALUES ELEVATED OUT OF THE FOUR, CONCLUSION IS THAT CLIENT HAS GESTATIONAL DIABETES MELLITUS INFECTION

1. VENEREAL DISEASE RESEARCH LABORATORY (VDRL) Test for syphilis Baby will get STD if delivered normally 2. HbSAg(+) Surface Antigen Mandatory on first pre-natal check-up If mother is HbS+ (reactive); she carries the virus o Health care provider requests for HbP protocol HbE antigen o If positive, therefore INFECTIVE and can infect baby HbSAg(+) and HbE(+) o Give vaccination to the baby o Active Hepatitis B vaccine 0.5 ml via I.M. Within 24 hours of delivery o Passive Hepatitis B immunoglobulin 0.5 ml I.M. Within 24 hours after delivery o Site of Choice Vastus lateralis Vitamin K Best site for administration o Rectus femoris Do not give vaccination on medial nerve (sciatic nerve) will be hit 79

Do not give on gluteus o Not developed o This is developed only when baby has begun to sit Do not give at deltoid o Deltoid is not developed Rectus femoris is the anterior muscle of the thigh Question HbSAg(+) mother Can she breastfeed? Answer Yes, provided baby should have received BOTH ACTIVE and PASSIVE VACCINATION PRIOR TO BREASTFEEDING

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