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MATERNAL/OB NOTES
Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes emotions and preferences
that are related to sexual self and eroticism.
2. Sex – basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.
B. Definitions related to sexuality:
Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as
sexual intercourse.
Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic
change.
- developed at the moment of conception.
fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn
during delivery.
Site – episiotomy.
d. Vestibule – an almond shaped area that contains the hymen, vaginal orifice and bartholene’s
glands.
B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and
weights.
Size- 1x2x3
Shape: nonpregnant pear shaped / pregnant - ovoid
Weight - nonpregnant – 50 -60 kg- pregnant – 1,000g
Pregnant/ Involution of uterus:
4th stage of labor - 1000g
2 weeks after delivery - 500g
3 weeks after delivery - 300 g
5-6 weeks after delivery - returns to original, state 50 – 60
C. ovaries – 2 female sex glands, almond shaped. Ext- vestibule int – ovaries
Function: 1. ovulation
2. Production of hormones
d. Fallopian tubes – 2-3 inches long that serves as a passageway of the sperm from the uterus to
the ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the
uterus.
4 significant segments
1. Infundibulum – distal part of FT, trumpet or funnel shaped, swollen at ovulation
2. Ampulla – outer 3rd or 2nd half, site of fertilization
3. Isthmus – site of sterilization – bilateral tubal ligation
4. Interstitial – site of ectopic pregnancy – most dangerous
3 Cylindrical Layers
2 corpora cavernosa
1 corpus spongiosum
Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into two
sacs, each of which contains a testes.
- cooling mechanism of testes
- < 2 degrees C than body temp.
- Leydig cell – release testosterone
2. Internal
The Process of Spermatogenesis – maturation of sperm
Male Female
Penile glans Clitoral glans
Penile shaft Clitorial shaft
Testes ovaries
Prostate Skene’s gands
Cowper’s Glands Bartholin's glands
Scrotum Labia Majora
IV. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these
stimulates the hypothalamus to release GnRF on LHRF
1.) Mittelschmerz – slight abdominal pain on L or RQ of abdomen, marks ovulation day.
2.) Change in BBT, mood swing
VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as
corpus luteum (secrets large amount of progesterone)
IX. 24th day if no fertilization, corpus luteum degenerate ( whitish – corpus albicans)
X. 28th day – if no sperm in ovum – endometrium begins to slough off to begin mens
2. Plateau Phase – (accelerated V/S) – increasing & sustained tension nearing orgasm. Lasts 30
seconds – 3 minutes.
3. Orgasm – (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension
with physiologic or psychologic release, immeasurable peak of sexual experience. May last 2 –
10 sec- most affected are is pelvic area.
A. Fertilization
B. Stages of Fetal Growth and Development
3-4 days travel of zygote – mitotic cell division begins
*Pre-embryonic Stage
a. Zygote- fertilized ovum. Lifespan of zygote – from fertilization to 2 months
b. Morula – mulberry-like ball with 16 – 50 cells, 4 days free floating & multiplication
c. Blastocyst – enlarging cells that forms a cavity that later becomes the embryo. Blastocyst –
covering of blastocys that later becomes placenta & trophoblast
d. Implantation/ Nidation- occurs after fertilization 7 – 10 days.
Fetus- 2 months to birth.
placenta previa – implantation at low side of uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization – corpus luteum continues to function & become source of estrogen &
progesterone while placenta is not developed.
3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion
Chorionic villi sampling (CVS) – removal of tissue sample from the fetal portion of the
developing placenta for genetic screening. Done early in pregnancy. Common complication fetal
limb defect. Ex missing digits/toes.
E. Cytotrophoblast – inner layer or langhans layer – protects fetus against syphilis 24 wks/6
months – life span of langhans layer increase. Before 24 weeks critical, might get infected
syphilis
1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion
2. GIT – transport center, glucose transport is facilitated, diffusion more rapid from higher to
lower. If mom hypoglycemic, fetus hypoglycemic
3. Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.
* Ectoderm – development of brain, skin and senses, hair, nails, mucus membrane or anus &
mouth
First trimester:
1st month - Brain & heart development
GIT& resp Tract – remains as single tube
1. Fetal heart tone begins – heart is the oldest part of the body
2. CNS develops – dizziness of mom due to hypoglycemic effect
Food of brain – glucose complex CHO – pregnant womans food (potato)
Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month
3. Sex organ formed
4. Meconium is formed
Third Month
1. Kidneys functional
2. Buds of milk teeth appear
3. Fetal heart tone heard – Doppler – 10 – 12 weeks
4. Sex is distinguishable
Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 – 20 weeks
3. buds of permanent teeth appear
Fifth Month
1. lanugo covers body
2. actively swallows amniotic fluid
3. 19 – 25 cm fetus,
4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks – multi
5. fetal heart tone heard with or without instrument
Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present
Eighth Month
1. lanugo begin to disappear
2. sub Q fats deposit
3. Nails extend to fingers
Ninth Month
1. lanugo & vernix caseosa completely disappear
2. Amniotic fluid decreases
Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus
A. Drugs:
Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing
& deafness
Tetracycline – staining tooth enamel, inhibit growth of long bone
Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia or pocomelia, absence of extremities
A. Systemic Changes
1. Cardiovascular System – increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc
of blood
- easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis – due to
hyperemia of nasal membrane palpitation,
Normal Values
Hct 32 – 42%
Hgb 10.5 – 14g/dL
Criteria
1st and 3rd trimester.- pathologic anemia if lower
HCT should not be 33%, Hgb should not be < 11g/dL
Pathogenic Anemia
- iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of
pregnant women.
- Assessment reveals:
• Pallor, constipation
• Slowed capillary refill
• Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia
Nursing Care:
• Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetable-
alugbati,saluyot, malunggay, horseradish, ampalaya
• Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered,
hematoma.
• Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or
2 hrs after, black stool, constipation
• Monitor for hemorrhage
Alert:
• Iron from red meats is better absorbed iron form other sources
• Iron is better absorbed when taken with foods high in Vit C such as orange juice
• Higher iron intake is recommended since circulating blood volume is increased and heme is
required from production of RBCs
Edema – lower extremities due venous return is constricted due to large belly, elevate legs above
hip level.
Mgt:
1.) Bed rest
2.) Never massage
3.) Assess + Homan sign once only might dislodge thrombus
4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute)
5.) Monitor APTT antidote for Heparin toxicity, protamine sulfate
6.) Avoid aspirin! Might aggravate bleeding.
2. Respiratory system – common problem SOB due to enlarged uterus & increase O2 demand
Position- lateral expansion of lungs or side lying position.
• Morning Sickness – nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet
30 minutes before arising bed. Nausea afternoon - small freq feeding. Vomiting in preg –
emesisgravida.
Metabolic alkalosis, F&E imbalance – primary med mgt – replace fluids.
Monitor I&O
constipation – progesterone resp for constipation. Increase fluid intake, increase fiber diet
- fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.
Except guava – has pectin that’s constipating – veg – petchy, malungay.
- exercise
-mineral oil – excretion of fat soluble vitamins
* Flatulence – avoid gas forming food – cabbage
*Hemorrhoids – pressure of gravid uterus. Mgt; hot sitz bath for comfort
4. Urinary System – frequency during 1st & 3rd trimester lateral expansion of lungs or side lying
pos – mgt for nocturia
Acetyace test – albumin in urine
Benedicts test – sugar in urine
5. Musculoskeletal
Waddling Gait – awkward walking due to relaxation – causes softening of joints & bones
Prone to accidental falls – wear low heeled shoes
Leg Cramps – causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause
while pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve
plexus
Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese,
yogurt, head of fish,
Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.
Vit D for increased Ca absorption
dorsiflexion
B. Local Changes
Local change: Vagina:
V – Chadwick’s sign – blue violet discoloration of vagina
C – Goodel's sign – change of consistency of cervix
I – Hegar's – change of consistency of isthmus (lower uterine segment)
S&Sx:
Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema
Mgt:
FLAGYL – (metronidazole – antiprotozoa). Carcinogenic drug so don’t give at 1st trimester
1. treat dad also to prevent reinfection
2. no alcohol – has antibuse effect
VAGINAL DOUCHE – IQ H2O : 1 tbsp white vinegar
3. Skin Changes – brown pigmentation nose chin, cheeks – chloasma melasma due to increased
melanocytes.
Brown pinkish line- linea nigra- symphisis pubis to umbilicus
Breast self exam- 7 days after mens –– supine with pillow at back
quadrant B – upper outer – common site of cancer
Cloasma
Linea negra
Increased skin pigmentation
Striae gravidarium
Quickening Goodel's- change of consistency of cervix
Chadwick’s- blue violet discoloration of vagina
Hegar's- change of consistency of isthmus
Elevated BBT – due to increased progesterone
Positive HCG or (+)preg test
Second Trimester – tangible S&Sx. mom identifies fetus as a separate entity – due to presence of
quickening, fantasy. Developmental task – accept growing fetus as baby to be nurtured.
Health teaching: growth & development of fetus.
3. Diagnosis of Pregnancy
1.) urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6 weeks after LMP-
best to get urine exam.
2.) Elisa test – test for preg detects beta subunit of HCG as early as 7 – 10days
3.) Home preg kit – do it yourself
4. Baseline Data: V/S esp. BP, monitor wt. (increase wt – 1st sign preeclampsia)
Weight Monitoring
First Trimester: Normal Weight gain 1.5 – 3 lbs (.5 – 1lb/month)
Second trimester: normal weight gain 10 – 12 lbs (4 lbs/month) (1 lb/wk)
Third trimester: normal weight gain 10 – 12 lbs (4 lbs/ month) ( 1lb/wk)
Minimum wt gain – 20 – 25 lbs
Optimal wt gain – 25 – 35 lbs
5. Obstetrical Data:
nullipara – no pregnancy
a. Gravida- # of pregnancy
b. Para - # of viable pregnancy
Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.
1 – 40th AOG GT P A L
1 – 36th AOG 6 1 2 2 4
2 – misc
1 – twins 35 AOG
1 – 4th month G6 P3
1 – 39th week
1 – miscarriage GP GTPAL
1 – stillbirth 33 AOG (considered as para) 4 2 4 11 1 1
1 – preg 3rd wk
1 – 33 P
1 41st L
1 – abort A
1 – still 39 GP GTPAL
1 triplet 32 6 4 6 2 2 15
1 4th mon
c. Important Estimates:
6 x 5 = 30 cm
7 x 5 = 35 cm 2nd ½ of preg
8 x 5 = 40 cm
9 x 5 = 45 cm
5. Physical Examination:
A. Examine teeth: sign of infection
Danger signs of Pregnancy
C - chills/ fever - infection
Cerebral disturbances ( headache – preeclampsia)
Result:
Class I - normal
Class IIA – acytology but no evidence of malignancy
B – suggestive of infl.
Class III – cytology suggestive of malignancy
Class IV – cytology strongly suggestive of malignancy
Class V – cytology conclusive of malignancy
7. Leopold’s Maneuver
Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of
descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone
- use palm! Warm palm.
Prep mom:
1. Empty bladder
2. Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles)
Procedure:
1st maneuver: place patient in supine position with knees slightly flexed; put towel under head
and right hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement
and firmness of the part to determine presentation
2nd Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart
sound) where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd
maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé.
Uterine soufflé – maternal H rate
3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers.
To determine degree of engagement.
Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will
not be movable).
4th Maneuver: the Examiner changes the position by facing the patient’s feet. With two hands,
assess the descent of the presenting part by locating the cephalic prominence or brow. To
determine attitude – relationship of fetus to 1 another.
When the brow is on the same side as the back, the head is extended. When the brow is on the
same side as the small parts, the head will be flexed and vertex presenting.
B. Nonstress test – to determine the response of the fetal heart rate to activity
Indication – pregnancies at risk for placental insufficiency
Postmaturity
a.) pregnancy induced hypertension (PIH), diabetes
b.) warning signs noted during DFMC
c.) maternal history of smoking, inadequate nutrition
Procedure:
Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor);
external monitor is applied to document fetal activity; mother activates the “mark button” on the
electronic monitor when she feels fetal movement.
Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good
Interpretation of results
i. reactive result
1. Baseline FHR between 120 and 160 beats per minute
2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15
seconds in a 10 to 20 minute period as a result of FM
3. Good variability – normal irregularity of cardiac rhythm representing a balanced interaction
between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system;
noted as an uneven line on the rhythm strip.
4. result indicates a healthy fetus with an intact nervous system
9. Health teachings
a. Nutrition – do nutritional assessment – daily food intake
High risk moms:
1. Pregnant teenagers – low compliance to heath regimen.
2. Extremes in wt – underweight, over wt – candidate for HPN, DM
3. Low socio – economic status
4. Vegetarian mom – decrease CHON – needs Vit B12 – cyanocobalamin – formation of folic
acid – needed for cell DNA & RBC formation. (Decrease folic acid – spina bifida/open neural
tube defect)
How many Kcal CHO x4,CHON x4, fats x 9
Adolescents have a higher protein requirement than mature women since adolescents must
supply protein for their own growth as well as protein t meet the pregnancy requirement
Zinc
Essential for
* the formation of enzymes
* maybe important in the prevention of congenital malformation of the fetus. 15mcg/day
representing an increase of 3 mg/day over prepreganant daily requirements. Zinc increases
should reflect
- liver, meats
- shell fish
- eggs, milk, cheese
- whole grains, legumes, nuts
Folic Acid, Folacin, Folate
Essential for
- formation of red blood cells and prevention of anemia
- DNA synthesis and cell formation; may play a role in the prevention of neutral tube defects
(spina bifida), abortion, abruption placenta 400 mcg/day representing an increase of more then 2
times the daily prepregnant requirement. 300mcg/day supplement for women with low folate
levels or dietary deficiency
4 servings of grains/day Increases should reflect
- liver, kidney, lean beef, veal
- dark green leafy vegetables, broccoli, legumes.
- Whole grains, peanuts
Additional Requirements
Minerals
- iodine
- Magnesium
- Selenium
175 mcg/day
320 mg/day
65 mcg/day Increased requirements of pregnancy can easily be met with a balanced diet that
meets the requirement for calories and includes food sources high in the other nutrients needed
during pregnancy.
Vitamins
E
Thiamine
Riborlavin
Pyridoxine ( B6)
B12
Niacin
10 mg/day
1.5 mg/day
1.6 mg/day
2.2 mg/day
2.2 mg day
17 mg/day Vit stored in body. Taking it not needed – fat soluble vitamins. Hard to excrete.
2.Sexual Activity
a.) should be done in moderation
b.) should be done in private place
c.) mom placed in comfy pos, sidelying or mom on top
d.) avoided 6 weeks prior to EDD
e.) avoid blowing or air during cunnilingus
f.) changes in sexual desire of mom during preg- air embolism
Changes in sexual desire:
a.) 1st tri – decrease desire – due to bodily changes
b.) 2nd trimester – increased desire due to increase estrogen that enhances lubrication
c.) 3rd trimester – decreased desire
Contraindication in sex:
1. vaginal spotting
1st trimester – threatened abortion
2nd trimester– placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane
Squatting – strengthen muscles of perineum. Increase circulation to perineum. Squat – feet flat
on floor
Raise buttocks 1st before head to prevent postural hypotension – dizziness when changing
position
4. Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while promoting wellness
behavior that can be used by parents and family thus, helping them achieved a satisfying and
enjoying childbirth experience.
a. Psychophysical
1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery
process. Based on imitation of nature.
Features:
1.) darkened rm
2.) quiet environment
3.) relaxation tech
4.) closed eye & appearance of sleep
2. Grantly Dick Read Method – fear leads to tension while tension leads to pain
b. Psychosexual
1. Kitzinger method – preg, labor & birth & care of newborn is an impt turning pt in woman’s
life cycle
- flow with contraction than struggle with contraction
Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis
Fontanels:
1.) Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18
months after birth- close
2.) Posterior fontanel or lambda – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.
4.) Anteroposterior diameter -
suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
occipitofrontal 12cm partial flexion
occipitomental – 13.5 cm hyper extension submentobragmatic-face presentation
2. Passageway
Mom 1.) < 4’9” tall
2.) < 18 years old
3.) Underwent pelvic dislocation
Pelvis
4 main pelvic types
1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow
3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
4. Platypelloid – flat AP diameter – narrow, transverse – wider
b. Pelvis
2 hip bones – 2 innominate bones
3 Parts of 2 Innominate Bones
Ileum – lateral side of hips
- iliac crest – flaring superior border forming prominence of hips
Ischium – inferior portion
- ischial tuberosity where we sit – landmark to get external measurement of pelvis
Pubes – ant portion – symphisis pubis junction between 2 pubis
1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis
1 coccyx – 5 small bones compresses during vaginal delivery
Important Measurements
1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the
symphysis pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true conjugate)
2. True conjugate/conjugate vera – measure between the anterior surface of the sacral
promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm
3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person – psychological stress when the mother is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP – most common malposition
Bear down with contractions
Adequate hydration – prepare for CS
Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is noted
Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix
into the vagina.
Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord form vagina
Nursing care:
1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain
slippery & prevent cord compression causing cerebral palsy.
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS
1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase:
Assessment: Dilations: 0 – 3 cm mom – excited, apprehensive, can communicate
Frequency: every 5 – 10 min
Intensity mild
Nursing Care:
1. Encourage walking - shorten 1st stage of labor
2. Encourage to void q 2 – 3 hrs – full bladder inhibit contractions
3. Breathing – chest breathing
Active Phase:
Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self
Frequency q 3-5 min lasting for 30 – 60 seconds
Nursing Care:
M – edications – have meds ready
A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.
D – dry lips – oral care (ointment)
dry linens
B – abdominal breathing
Pelvic Exams
Effacement
Dilation
a. Station – landmark used: ischial spine
- 1 station = presenting part 1cm above ischial spine if (-) floating
- 2 station = presenting part 2 cm above ischial spine if (-) floating
0 station = level at ischial spine – engagement
+ 1 station = below 1 cm ischial spine
+3 to +5 = crowning – occurs at 2nd stage of labor
b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the
mother
-spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
cephalic - Vertex – complete flexion
Face
Brow Poor Flexion
Chin
Breech - Complete Breech – thigh breast on abdomen, breast lie on thigh
Incomplete Breech – thigh rest on abdominal
Frank – legs extend to head
Footling – single, double
Kneeling
c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.
Variety:
Occipito – LOA left occipito ant (most common and favorable position)– side of maternal pelvis
LOP – left occipito posterior
LOP – most common mal position, most painful
ROP – squatting pos on mom
ROT
ROA
Parts of contractions:
Increment or crescendo – beginning of contractions until it increases
Acme or apex – height of contraction
Decrement or decrescendo – from height of contractions until it decreases
Duration – beginning of contractions to end of same contraction
Interval – end of 1 contraction to beginning of next contraction
Frequency – beginning of 1 contraction to beginning of next contraction
Intensity - strength of contraction
Contraction – vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or midway of contractions
Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify MD
-preeclampsia
Health teachings
1.) Ok to shower
2.)NPO – GIT stops function during labor if with food- will cause aspiration
3.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.)Sims position/side lying
12 – 18 inch – ht enema tubing
Mechanisms of labor
1. Engagement -
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion
Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides
the false and true pelvis.
Nursing Care:
To prevent puerperal sepsis - < 48 hours only – vaginal pack
3. Third Stage: birth to expulsion of Placenta -placental stage placenta has 15 – 28 cotyledons
Placenta delivered from 3-10 minutes
Signs of placental separation
1. Fundus rises – becomes firm & globular “ Calkins sign”
2. Lengthening of the cord
3. Sudden gush of blood
Types of placental delivery
Shultz “shiny” – begins to separate from center to edges presenting the fetal side shiny
Dunkan “dirty” – begin to separate form edges to center presenting natural side – beefy red or
dirty
4. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage. Monitor v/s q 15
for 1 hr. 2nd hr q 30 minutes.
Check placement of fundus at level of umbilicus.
d. Perineum –
R - edness
E- dema
E - cchemosis
D – ischarges
A – approximation of blood loss. Count pad & saturation
Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock
if with bleeding.
Earliest sign: tachycardia & restlessness
Late sign: hypotension
Outstanding Nursing dx: fluid volume deficit
Post of mom – modified trendelenberg
IV – fast drip due fluid volume def
Uterine Rupture
Causes: 1.)
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:
a.) sudden pain
b.) profuse bleeding
c.) hypovolemic shock
d.) TAHBSO
Physiologic retraction ring
- Boundary bet upper/lower uterine segment
BANDL’S pathologic ring – suprapubic depression
a.) sign of impending uterine rupture
Amniotic Fluid Embolism or placental embolism – amniotic fluid or fragments of placenta enters
natural circulation resulting to embolism
Sx:
dyspnea, chest pain & frothy sputum
prepare: suctioning
end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body –
eyes, nose, etc.
Trial Labor – measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor
Multi: 8 – 14, primi 14 – 20
Home Mgt:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 -4 glasses of water – full bladder inhibits contractions
5. consult MD if symptoms persist
Hosp:
1. If cervix is closed 2 – 3 cm, dilation saved by administer Tocolytic agents- halts preterm
contractions.YUTOPAR- Yutopar Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IV
Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) – sustained tachycardia
Antidote – propranolol or inderal - beta-blocker
A. Physiologic Changes
a.1. Systemic Changes
1. Cardiovascular System
- the first few minutes after delivery is the most critical period in mothers because the increased
in plasma volume return to its normal state and thus adding to the workload of the heart. This is
critical especially to gravidocardiac mothers.
2. Genital tract
a. Cervix – cervical opening
b. Vaginal and Pelvic Floor
c. Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10th day – no
longer palpable due behind symphisis pubis
3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a
medium for bacterial growth- (puerperal sepsis)- D&C
after, birth pain:
1. position prone
2. cold compress – to prevent bleeding
3. mefenamic acid
3. Urinary tract: Bladder – freq in urination after delivery- urinary retention with overflow
4. Colon: Constipation – due NPO, fear of bearing down
5. Perineal area – painful – episiotomy site – sims pos, cold compress for immediate pain after
24 hrs, hot sitz bath, not compress
sex- when perineum has healed
c. Letting go – interdependent phase – 7 days & above. Mom - redefines new roles may extend
until child grows.
I. Early postpartum hemorrhage– bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse
bleeding – uterine atony. Complications: hypovolemic shock.
Mgt:
1.) massage uterus until contracted
2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip
Breast feeding – post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
- assess perineum for laceration
- degree of laceration
- mgt episiorapy
II. Late Postpartum hemorrhage – bleeding after 24 hrs – retained placental fragments
Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta
increta, percreta,
Gen mgt:
1.) supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture &
sensitivity – for antibiotic
OVULATION –count minus 14 days before next mens (14 days before next mens)
Origoknause formula –
- monitor cycle for 1 year
- -get short test & longest cycle from Jan – Dec
- shortest – 18
- longest – 11
June 26 Dec 33
- 18 -11
8 - 22 unsafe days
Physiologic Method-
Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland
production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9%
effective. Waiting time to become pregnant- 3 months. Consult OB-6mos.
-in case a mother who is taking an oral contraceptive for almost long time plans to have a baby,
she would wait for at least 3 months before attempting to conceive to provide time for the
estrogen and progesterone levels to return to normal.
- if a new oral contraceptive is prescribed the mother should continue taking the previously
prescribed contraceptive and begin taking the new one on the first day of the next menses.
- discontinue oral contraceptive if there is signs of severe headache as this is an indication of
hypertension associated with increase incidence of CVA and subarachnoid hemorrhage.
Signs of hypertension
Immediate Discontinuation
A – abdominal pain
C – chest pain
H - headache
E – eye problems
S – severe leg cramps
If mom HPN – stop pills STAT!
Adverse effect: breakthrough bleeding
Contraindicated:
1.) chain smoker
2.) extreme obesity
3.) HPN
4.) DM
5.) Thrombophlebitis or problems in clotting factors
- if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day.
If forgotten for two consecutive days, or more days, use another method for the rest of the cycle
and the start again.
Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.
- 5 yrs – disadvantage if keloid skin
- as soon as removed – can become pregnant
HT:
1.) Check for string daily
2.) Monthly checkup
3.) Regular pap smear
Alerts;
- prevents implantation
- most common complications: excessive menstrual flow and expulsion of the device (common
problem)
- others:
P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic pregnancy
Condom – latex inserted to erected penis or lubricated vagina
Adv; gives highest protection against STD – female condom
Alerts:
Disadvantage:
- it lessen sexual satisfaction
- it gives higher protection in the prevention of STDs
Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the
uterus. REVERSABLE
Ht:
1.) proper hygiene
2.) check for holes before use
3.) must stay in place 6 – 8 hrs after sex
4.) must be refitted especially if without wt change 15 lbs
5.) spermicide – chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome
Surgical Method – BTL , Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid
lifting heavy objects
Vasectomy – cut vas deferense.
HT: >30 ejaculations before safe sex
O – zero sperm count, safe
1. Hemorrhagic Disorders
General Management
1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
4.) Ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Save discharges – for histopathology – to determine if product of conception has been
expelled or not
Classifications:
a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
b. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
Types:
1.) Complete – all products of conception are expelled. No mgt just emotional support!
2.) Incomplete – Placental and membranes retained. Mgt: D&C
Incompetent cervix – abortion
McDonalds procedure – temporary circlage on cervix
S/E; infection. During delivery, circlage is removed. NSD
Sheridan – permanent surgery cervix. CS
C. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity. common site:
tubal or ampular
Dangerous site - interstitial
Unruptured Tubal rupture
- missed period
- abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)
- scant, dark brown, vaginal bleeding
Nursing care:
Vital signs
Administer IV fluids
Monitor for vaginal bleeding
Monitor I & O - sudden , sharp, severe pain. Unilateral radiating to shoulder.
shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic
nerve)
+ Cullen’s Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding
syncope (fainting)
Mgt:
Surgery depending on side
Ovary: oophrectomy
Uterus : hysterectomy
D. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine
segment, sometimes covering the cervical os. Abnormal lower implantation of placenta.
- candidate for CS
Sx: frank
Bright red
Painless bleeding
Dx:
Ultrasound
Avoid: sex, IE, enema – may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR
Assessment:
Engagement (usually has not occurred)
Fetal distress
Presentation ( usually abnormal)
Surgeon – in charge of sign consent, RN as witness
- MD explain to patient
complication: sudden fetal blood loss
Nursing Care
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV
E. Abruptio Placenta – it is the premature separation of the placenta form the implantation site. It
usually occurs after the twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.
Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due
to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
-placenta previa & vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
Strict I&O
F. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel may
lead to retained placental fragments if vessel is cut.
G. Placenta Circumvalata – fetal side of placenta covered by chorion
H. Placenta Marginata – fold side of chorion reaches just to the edge of placenta
I. Battledore Placenta – cord inserted marginally rather then centrally
J. Placenta Bipartita – placenta divides into 2 lobes
K. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
L. Vasa Previa – velamentous insertion of cord has implanted in cervical OS
2. Hypertensive Disorders
I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post
partum.
III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post
partum.
Three types of pre-eclampsia
1.) Mild preeclampsia – earliest sign of preeclampsia
a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2
Cause of preeclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake of CHON
Nursing care:
P – romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will
cause to urinate.
P- prevent convulsions by nursing measures or seizure precaution
1.) dimly lit room . quiet calm environment
2.) minimal handling – planning procedure
3.) avoid jarring bed
Newborn Effect : DM
1.) hyperinsulinism
2.) hypoglycemia
normal glucose in newborn 45 – 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test – get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer dextrose
3.) hypocalcemia - < 7mg%
Sx:
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium
Recommendation
Therapeutic abortion
If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant – heparin doesn’t cross placenta
Heart disease
Moms with RHD at childhood
Class I – no limit to physical activity
Class II – slight limitation of activity. Ordinary activity causes fatigue & discomfort.
Class III - moderate limitation of physical activity. Ordinary activity causes discomfort
Recommendation:
1.) early hospitalization by 7 months
Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort.
Recommendation: Therapeutic abortion
Procedure:
a. classical – vertical insertion. Once classical always classical
b. Low segment – bikini line type – aesthetic use
2 types of infertility
1.) primary – no pregnancy at all
2.) Secondary – 1st pregnancy, no more next preg
test male 1st
- more practical & less complicated
- need: sperm only
- sterile bottle container ( not plastic has chem.)
- Sims Huhner test – or post coital test. Procedure: sex 2 hours before test
mom – remains supine 15 min after ejaculation
Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If >15 – low sperm
count
Best criteria- sperm motility for impotency
Factors: low sperm count
1.) occupation- truck driver
2.) chain smoker
administer: clomid ( chomephine citrate) to induce spermatogenesis
Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm count
Implant sperm in ampula
2.) Tubal Occlusion – tubal blockage – Hx of PID that has scarred tubes
- use of IUD
- appendicitis (burst) & scarring
= dx: hysterosalphingography – used to determine tubal patency with use of radiopaque material
Mgt: IVF – invitrofertilization (test tube baby)
England 1st test tube baby