Maternal and Child Nursing

OVERVIEW OF THE REPRODUCTIVE SYSTEM  Imperforate

FEMALE o May lead to
Breast Pseudoamenorrhea/Cryptomenorrhea
 Dependent on the ovary for hormones o Management is surgery; put to sleep to prevent
 During menopause  stop supply of hormones  prone to damage to vagina
cancer  Rigid
Mons Pubis o Problem with intercourse
Labia o Management is surgery
 Serves as a covering  Carunculae Myrtiformes - remnants of hymen after tearing
 Majora and minora
 Minora - has erectile tissues (clitoris) Doderlein’s bacillus
 Normal flora
- Clitoris  Bacteria that protects the woman from bacterial infection
 Anterior  Makes vagina acidic
 Basis for catheterization  Candida albicans (candidiasis) (moniliasis)- most common
 Avoid touching the clitoris when inserting the infection in the woman
catheter – may cause convulsion in precclamptic o Yeast infection
patients o Color (#1 assessment) - Yellowish creamy color
- Fourchette o Consistency of discharge: thicker
 Posterior of minora o Smell: no smell
 Stretch during delivery napupunit o Pruritus
 Ritgen’s Maneuver o Vaginal suppository (MICONAZOLE, MONISTAT)
o Perineal support  Local effect only
o Protect the are from overstretching  Best time to insert the vaginal
 Episiotomy suppository: night time  patient not
o Prevents laceration upright  drug is dissolved in vagina
o Cut during peak of contraction  all the  6 hours for drug to take effect
muscles are pulled up and no muscles are  Should report MORE discharge; drug
cut and infection (only 1 day)
o Should have anesthesia  Only needs a single dose
o How many strong contractions before o Effect on Baby: infection on baby’s MOUTH (Oral
episiotomy: 3 moniliasis)
o Mediolateral- hindi mag eextend to anus
but many layers of tissues are affected  Trichomonas vaginalis
(Most common incision made) o SMELLY!!!!!!!!!
o Median- used for immediate delivery, may o Greenish grayish frothy
extend to anus  Gonorrheal
- Vestibule o Effect on baby: eyes
o Triangle  Chlamydial
o Two important openings- 2 (urethra and o Effect on baby: eyes
vagina) Cervical Mucus
o All openings- 6  From cervical glands - Spinbarkeitt
Urethra  Endocervical gland in cervix
 Urethral canal is very short  at risk for infection 2 hormones that affects the cervix
o 8-10 glasses of fluid / 50% should be plain water  Estrogen
 UTI- increase fluids because no matter how much you do  Progesterone
perineal care, the proximity of the urethra to still
predisposes it to infection Estrogen Progesterone
-Dilates the cervix -Closes the cervix
*Because of hormone change, pregnant is more at risk for infection -Released before ovulation: -Released on the 16th day
 progesterone  decreased renal threshold of sugar  small 14th day -Mucus is decreased in amount,
amount leak out  sugar in vagina is good medium for bacterial -Mucus is watery, clear, sticky, cloudy
growth stretchy -Spinnbarkheit: 3 cm
-Spinnbarkheit: 6-12 cm -Safe Period
Vagina -Unsafe period -Ph: 6
 Discharge: Fleshy smelling (Normal: 6-8 soaked napkin = -13th day of the 28th day -Hormone that protects the
30ml of blood) cycle baby
 More than 2000ml = shock -For 3-5 days -Dec. progesterone (AP) = Inc.
 Organ for copulation -Ph: 8 oxytocin (PPG)
 During birth passage no ruggae (less resistance) for
easier passage of the baby Operculum
 Has ruggae (folds of muscles) which allow to stretch  Mucus that plugs the cervix
 Kegel’s exercise- to promote formation of ruggae  More discharge  formation of mucus plug
o Pubo-coccygeal muscle  Protects the baby from possible entry of infection
o Contract the muscle to hold the urine, then  “Show”- sign of cervical dilation
release the muscle  Cervical dilation- indication that the woman has started
o Done as much as she wants labor
Hymen
 Pag nastretch ang vagina, stretch din ang hymen

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 Maternal and Child Nursing
Uterus
 Estrogen- thickens the muscle (hypertrophy)
 Progesterone- relaxes the uterus, maintains the pregnancy
 Upper Segment(Fundus)
o most active segment of the uterus
o Muscles are found in all directions ”figure of 8”
o Upper central and posterior segment- best site
for implantation of placenta
 Placenta previa- bigger placenta
o Placenta obstruct the passage way
o Bleeding from the placenta
 Painless
 Last trimester
 Lower Segment
o Passive segment
o Longitudinal muscles
 During contraction, same shape of uterus (globular
shaped)
 Physiologic retraction ring (normal)
o Imaginary line that separates the upper and the
lower segment of the uterus during labor
o Not seen but palpable
 Pathologic retraction ring (Bandle’s ring)
o There is an overstretching of the uterus
o Visible separation of the upper and lower
segment of the uterus
o There is an obstruction of the baby’s
passageway
 Distended bladder
 Make sure the patient voids
every 2 hour intervals
 Straight catheter
 Cephalo-pelvic disproportion
 Perimetrium
 Myometrium
 Endometrium
o 1.5 cm thick due to influence of estrogen and
progesterone (supplied by the ovary) (release
estrogen and progesterone simultaneously)
o During pregnancy  6 cm thick
 Protective mechanism of the hormones
to maintain the lining for the
 DECIDUA- endometrium during
pregnancy
 Estrogen and progesterone released at
the same time
 Hormones in the ovary are at rest,
PLACENTA takes over supply of
hormones
 3 months before the woman starts
menstruating again
 Decidua Basalis – where
placenta is attached; E and P
maintain it
o Zona basalis –
remains when
decidua is shed; new
endometrium for
next pregnancy
 Decidua Vera
 Decidua Capsularis
 Lochia – shedding of the deciduas
 Alba and serosa are odorless
 Menstruation – shedding of the lining
o Breastfeeding
 Form of birth control
 Only up to 6 months
 Suppress the activity of the ovary
University of Santo Tomas – College of Nursing / JSV
 Baby suckes stimulation of prolactin
and oxytocin
 Baby suckles  stimulation of anterior
pituitary (estrogen and prolactin)
 Only 1 or the other can be
released
 Estrogen stimulates ovulation so during
breastfeeding prolactin I released
instead of estrogen
 Prolactin  increase production of milk,
insulin antagonist
 Oxytocin  ejection of the milk, uterine
contraction, released during labor
 8 times of feeding
 6 times daytime
 2 times at night
 at 6 months, introduction of other foods
to baby  decreased breastfeeding 
estrogen instead of prolactin released
o Is there a difference between menstrual and
lochial discharge?
 *Menstrual blood: NEVER CLOTS
 Color: SAME
 Smell: SAME
 Amount: DIFFERENT (more on lochia)
 Menstruation: 30-50 ml (max
80 ml)
 Lochia: difficult to estimate
 #of days of menstrual flow: 2-6 days
o Lochia
 Rubra: 3 days
 Actual bleeding
 Presence of clots: report
 Serosa: at least 1 week
 Alba: 3 weeks or more (3-5 weeks)
 Braxton Hicks
o Started at 4 months
o Contractions more significant at 7th month
o Decreasing level o progesterone at the last
trimester  increase frequency of contraction
 Labor
o Decrease progesterone  release of oxytocin
o Prostaglandin theory
 Hormone release by the when the
body is stressed
 Acts on the muscles
 From the placenta, uterus, fetus
 Sudden increase in prostaglandin
 Mefenamic acid- prostaglandin
inhibiting drug
 Take on the day before you
menstruate or at the onset of
menstruation
o Uterine Stretch theory
 When uterine is stretch to its max
capability and capacity, it will naturally
contract and expel its contents
 Natural protective capacity of the
organ
o *Conditions will stretch early
 Twins (needs delivery; will deliver earlier)
2 weeks earlier
 polyhydramnios
 macrosomic baby
*Safe ang Sex even during pregnancy
 Safe up to 34th week of pregnancy
o Semen contains prostaglandin  increase
prostaglandin  early onset of labor
 Maternal and Child Nursing
Fallopian Tube Bulbourethral gland (Couper’s)
 As long as fallopian tube is healthy, fertilized egg can pass  Stimulated only during sexual arousal
through  Cleans the urethra
 Isthmus Ejaculate
o Ligated in tubal ligation  2.5-5ml
o Estrogen – propel by rhythmic movements  at least 50,000,000/ml
o Progesterone – nourishment of the zygote  Low sperm count: less than 20,000,000/ml
 Ampulla  300,000,000 per ejaculate
o Fertilization- outer 3rd of the ampulla (distal  Pre-ejaculation:
portion)  Irregardless of number, only 1 sperm can get a woman
 Fibrae pregnant
 Cause of ectopic pregnancy  If sperm is mature, can enter the woman’s uterus 80
o Surgery from tubal ligation (most common seconds!!!!
cause) (1% chance that it will recanalized)  Characteristic of the Sperm
o Pelvic inflammatory disease o Small head with long tail
o Recurrent UTI infections o Length of the tail is 10x the length of the head
 Development of the reproductibe organ- estrogen o Neck- gives energy to tail
o Transport of baby through the tub (average of 1 o Head- gives chromosomes
week) o Tail- propels the sperm
 Never earlier than 7 (7-10) o Unidirectional- paakyat!
o Rhythmic contraction of the fallopian tube
 Progesterone MENSTRUAL CYCLE
o Nourishment of the baby in the tube  the start of every cycle is the menstrual cycle
Ovary/Ovulation Hormones
 Primordial ova (at birth): 300,000-400,000  Hypothalamus: GnRh – stimulates APG
o Immature follicle  Anterior Pituitary Gland: FSH, LH
o Some die before they mature o FSH- stimulates development of graafian follicle
 By age 7: reduce to ½ in number o Leutenizing Hormone (LT) or Interstitial Cell
 Number that reach maturation: around 400 (200/day) Stimulating Hormone - stimulates ovulation and
 Menarche: 9-17 years old development of ovary
 Reproductive period: 35 years o The time the FSH stopped is the time of the
 Menopause sudden increase in LH
o Perimenopause  Ovary: Estrogen, Progesterone
 2-10 years before menopause; o Estradiol – from the ovary
hormone imbalance o Estriol – from the placenta
 34-60 years of age o Progestin – progesterone form ovary and
 Vasomotor instability, irregular periods, placenta
sleep trouble, irritability  Corpus luteum- 2 weeks
o Menopause  Albicans- dead corpus luteum
 End of menstruation/Cessation of  Corpus luteum degenerates  corpus albicans
menses decreased estrogen and progesterone (ischemic) 
 Possibility that 1 or 2 egg cells are still in shedding of endometrium  Bleeding (Menstrual) – start
the ovary; risk of having a baby with of the cycle
chromosomal defects  Low levels of E and P  stimulate hypothalamus: GnRh 
o Post Menopause stimulate anterior pituitary gland  release of FSH 
 1 year after menopause; very low level stimulates the follicle to mature  Graafian Follicle
of estrogen (increased ESTROGEN)  Endometrium Thickens
(Proliferative)
 Increased LH  Ovulation  Corpus luteum
progesterone  further thickens at endometrium, more
vascular  ready for implantation (Secretory)

MALE FSH LH
Scrotum - protects the testes from temperature
Penis - organ of copulation Estrogen Progesterone
Urethra
 Releases urine and semen  Menstrual phase- degeneration of the endometrium
 Glans penis- with an angle so it could reach the posterior  Ischemic phase- corpus albicans
of the vagina  Menopause
Testes o Fsh is forever increased
 Where sperm s produces  Effect of combined birth control pills on ovary
Epididymis o Prevent ovulation
 Store house of sperms  Menstruation
Vas Deferens o Degeneration of corpus luteum
 Conduit between the epididymis and ejaculatory dock  Activity of ovary during Pregnancy
Seminal fluid with fructose o No ovulation
Prostate gland  Best hormonal requirement for ovulation
 Add volume of fluid o Increased FSH and LH
 Makes sperm alkaline  Suckling -> prolactin -> dec. estrogen

University of Santo Tomas – College of Nursing / JSV

 Maternal and Child Nursing
 Average mentstrual blood loss = 30-50ml
 Normal span = 21-28 days, at maximum 35 days
 Oligomennorhea- prolonged intervals between menses
 Polymenorrhea- short intervals between menses
 Metrorrhagia – intercyclic bleeding
 Hypomenorrhea- scanty flow of bleeding, caused by
nutrient deficiency or hormonal imbalance
 Hypermenorrhea/Menorrhea- excessive menstrual flow,
caused by endocrine imbalance, infection
 Primary Amennorhea
o Failure to begin to menstruate by 16 years of age
o If absence of breast development or pubic hair,
then consider Turner’s syndrome (female with
only one X chromosome)
o No development of secondary sex
characteristics
Menopause
 Osteoporosis
o Estrogen
o Absorption of calcium
o Retention of calcium  decreased in
menopause
o Signs in Of Osteoporosis
 Dowager hump (kyphosis)
 Decrease in height
 More prone to spontaneous fractures
(wrist fracture common)
 Pelvic fracture- dangerous
 Weight is on the area of the
pelvis  bone unable to
support
o Management
 Walking devices
 Allendronate (Fosamax) – prevents
bone resorption
 Take in the morning with
plenty of water, 30 mins
before eating
 Stay upright for 30 mins after
talking to avoid reflux and
other GI symptoms
 Calcitonin – allows calcium to go to the
bones
o Preventive Measures
 Increase calcium in diet
 1500-1800 mg/day
 Exercise using the bigger bones/ weight
bearing exercise
 Walking
 Stair climbing
 Dancing
 Avoid injurious activities
 Sports with bouncing or
jogging
 Bone Density Scan once a year
 Breast Cancer
o 1 out of 7,000,000
o Prolonging the life the woman if diagnosed early
 Breast Self-Exam
o Schedule: 1 week after menstruation when
estrogen can’t influence breast tissue
o Menopause: breast self-exam at the same date
every month
o Breastfeeding: same date of each month
o Steps
 Face the mirror
 Raise both hands
 Should pull up at the same
time
University of Santo Tomas – College of Nursing / JSV
 If one is pull down- unusual
heaviness
 Put your hand on your waist and lean
forward
 Must point at the same
direction
 Palpate (person should raise the hand
at the back of the head
 Circular
 Tail method/Tail of Spencer
(outer quadrant going to inner
quadrant)
 Feel for any lumps
 Squeeze the nipple between thumb
and forefinger to observe for any
discharge; abn if w/ secretion
 Mammogram
o Procedure to detect for any abnormal growth
o Starts at age 40-50 years; done every 2 years
o 51 and above: yearly
o Women of low risk category
o Women of high risk category
 From age 40, every year
 With family history of breast cancer
 Menopause after 50
 Nulliparous
 History of benign growth on the breast
(fibroadenoma)
 Heart Disease (atherosclerosis)
o 1 year after menopause  start to increase
cholesterol levels
o Peaks at 5 years
o Estrogen increases HDL decrease estrogen at
menopause  decrease HDL  increase LDL
o Prevention:
 Diet - reduce intake of fatty foods
 Exercise
 Stress Reduction
 Lifestyle change
 Exercise
 Diet
 Pap Smear
o First papaniculao smear
o Age:21
o Earlier if sexually active (3 years after the first
sexual activity)
o Then annually until 3 consecutive negative Paps
 I – normal cells
 II – abnormal cells but not malignant,
suggests infection
 III – abnormal cells, suggests
malignancy, do cervical biopsy
 IV – abnormal cells, malignancy (no
biopsy)

FAMILY PLANNING
 After intercourse, diaphragm should be in place for 6
hours
 3 year spacing of children; mandated by WHO
Major Program Policies of the Philippine Family Planning Program
 Improvement of family welfare with the main focus on
women’s health, safe motherhood and child survival
 Promotion of family solidarity and responsible parenthood
 Nurses as EDUCATOR and FACILITATOR
 How many methods: 6
 Maternal and Child Nursing
Methods of Family Planning
1. Behavioral
o Coitus Reservatus - no sexual activity
o Coitus Withdrawal/Interruptus - with sexual
activity
 Sperm is not released inside the
woman’s body
 Not an accidental pregnancy 
unwanted
 Never taught
2. Natural Family Planning
- Principles:
o The human ovum is susceptible to fertilization
only for 18 to 24 hours
o The sperms deposited in the vagina are capable
of fertilizing the ovum for no more than 72 hours
o Present methods of determining ovulation are
not exact by about 48 hours
o Calendar Method
 Ogino-knaus formula
 Regular- same interval each time
 Subtract 12 from the number
of days of the menstrual cycle
to determine day ovulation
 Abstinence starts 5 days
before ovulation and lasts up
to 3 days after ovulation
 Important: 1st day of the last
menstrual cycle
 9 days of abstinence – Rule of
9’s
 Irregular- data of shortest cycle and
data of longest cycle; for 6 months
 Subtract 18 from the short
cycle and subtract 11 from
the long cycle
 13 days abstinence
 Answer of shortest to answer on
longest  abstinence
 While waiting for 6 months, she can
use other natural family planning
method
Menstrual interval
 Interval between the first day of menstruation from the
next menstrual cycle
o Basal Body Temperature
 Any route for temp
 Pre-ovulatory temperature is low
because of high estrogen level
 Post-ovulatory temperature rise is due
to high progesterone level
 How many will you abstain from day
of change of temp: 3 days (egg cell
can survive for only 24 hours, 2 days
leeway)
o Symptothermal Method
 Combination of mucus and temp
method
 More conclusive since it has 2
parameters
o Billings/Cervical Mucus Method
o Lactational Amennorhea Method
3. Chemical
o Use of spermicides
o Makes the vagina more acidic
o Common side effect: vaginitis
University of Santo Tomas – College of Nursing / JSV
 Woman is not capable of protecting
the vaginal wall
o Delivery bases
 Cream,jelly
 Foam
 Film
 Suppositories – mostly used in the PH
 Foaming tablets
o Common chemical agents
 Nonoxynol-9 (N-9) – kills sperm, virus,
and bacteria
 menfegol
 benzalkonium chloride (BZK)
4. Local barrier
o Diaphragm
 Dome shaped; mustbe fitted by MD
 No protection from infection
 Inserted up to 2 hours before
intercourse and removed 6 hours
after intercourse to kills all sperms
 Should be fitted exactly
 Covers cervix and posterior portion of
the vagina
 Can be tilted during intercourse
 Spermicide should cover inner
portion, outer portion and rim of the
diaphragm
o Cervical Cap
 No protection from infection
 Harder to place but one size fits all
 The contraceptive sponge is
moistened well with water and
inserted into the vagina with the
concave portion positioned over the
cervix; may stick to the cervix
 Wash hands thoroughly before
inserting the cap
 Wear it while upright placing one leg
on a stool to feel the cervix
 24-48 hours- time you can keep it
 Longer than 48 hours  develop
infection  toxic shock syndrome
 Might develop cervicitis
o Condom
 Made of latex - allergenic
o Female Condom
 30% effective
5. Hormonal (Anovulatory menstruation)
o Prevent pregnancy by inhibiting the
hypothalamus and anterior pituitary so that
ovulation does not occur
o Injectable
 Depo-provera
 Depo-medroxyprogesterone – no
estrogen, interfere with insulin use;
not given to diabetics
 3 month injectable contraceptive
containing 150 mg of synthetic
progestin
 Increase (excessive) thickness of the
endometrium
 Avoid massaging the area 
immediate absorption  effectivity
less than 3 months
 Don’t move site/arm – increase
absorption
 Maternal and Child Nursing
 Slow gentle wrist motion- prevent
bubbles to give complete dose
prescribe
 Cost effective; given every 3 months;
not readily reversible
 Mixed slowly
o Implant
 Norplant; Non-absorbable
 Synthetic progestin
 Implanted on the upper arm
 Should be felt but not seen
 Suppresses ovulation for 5 years
 6 capsules of progestin are inserted
SQ in the woman’s upper arm;
contraceptive effective lasts up to 5
years
 2 years- 98-99%
 Every year minus 1%
o Oral
 Oral contraceptive pill; reversible
 Available in 21 and 28 day
preparation
 7 placebo- iron supplement
 Must be taken according to the
arrow
 1st day of menstruation- start intake of
pill (28 day prep)
 5th day of menstruation- start of
intake of pills (21 day prep)
 Take pill with food (after a meal)-
prevent gastric irritation
 Whatever time is convenient- best
time to take the pill
 If forgot to take the pill in the
morning- take pill now then take pill
the time she regularly takes it the
next day
 If she forgot the day before- take
double dose and continue regular
schedule
 2 days missed dose, double dose
today and tomorrow then return to
normal schedule
 3 days missed – stop taking and start
and new one and use another
method
 Side effect:
 Nausea
 Breast tenderness
 Weight gain- 5 lbs. every year
 Breakthrough bleeding
 Adverse effect:
 A- abdominal pain (severe),
due to hepatotoxicity
 C- chest pain (severe) or
shortness of breath
 H- headaches (severe)
 E- eye problems (blurred
vision, loss of vision), inc. BP
 S- severe leg pain (calf or
thigh) DVT
 Mini pill
 Progestin only
 Morning after pill
 Patients who are raped
 Damage the development of
the ovum
 Contains a lot of estrogen
 Contraindications
University of Santo Tomas – College of Nursing / JSV
 Undiagnosed vaginal
bleeding
 Thromboembolic disorders
 Pregnancy – terratogenic
 Liver disease
 Coronary artery or
cerebrovascular disease
 Heavy cigarette smoking –
effect on vessels
 Breastfeeding – suppress
estrogen
INTRAUTERINE DEVICE (IUD)
 A small, usually flexible appliance inserted into the uterine
cavity
 Inserted only when the woman is menstruating
o To be also sure that woman is not pregnant
o Only time cervix can open
 Disrupts normal uterine environment; abnormal lining
 MD insert instrument to measure length of uterine cavity 
insert IUD as he pulls applicator
 String is cut
 Inhibits implantation through:
o Local inflammatory response
o Loal production of prostaglandins
o Interfere with enzymatic and hormonal activity
o Increase motility of ovum in fallopian tube
 It immobilizes the sperms as they pass through the uterus
 ABORTIFACIENT
 Tell patient to check her string once a week for the first
month
 CHECK HER String once a week after insertion/once a
month after menstruation
 Inserted during menstruation
 If string not felt, go to doctor!
 Progesterone-coated- changed every year
 Copper T- every 10 years, spermicide
*Pelvic Inflammatory disease
 Complication of IUD for 10 years
 If woman with PID is still with IUD in place
o Treat infection (antimicrobial) first before
removal of IUD
 Danger Signs
o P- period late or skipped period
o A- abdominal pain (severe)
o I- increased temperature, chills
o N- noticeable vaginal discharge; foul-smelling
discharge
o S- spotting, bleeding, heavy periods, clots
6. Surgical
o Vasectomy
 Local infiltration__> incision 
separate vas deferens pull out 
tie  cut
 A minor surgery
 Scrotal area will be swollen within 2-3
days
 Can resume intercourse as soon as
the inflammation subsides
 Wear a condom (1 month)
a. 2-3 times per week
 Sperms are already produced
 2-20- ejaculations needed to remove
all ejaculation
 Maternal and Child Nursing
 After 1 month, get sperm count if  Positive pregnancy test, Goodell’s, ballotment,
negative  wait for another month Chadwick’s, Hegger’s, inc. abdominal sign, Braxton hicks
 get sperm count again contraction
 (-) (-)- OK na Positive
 3rd sperm count- 1 year after  Diagnostic
vasectomy  Fetal heart (low pitch) - funic soufflé (high pitch)
 Sperms that are newly developed  Fetal outline
and cannot be released is  Palpation of fetal parts by the examiner through Leopold’s
REABSORBED by the body maneuver
 64 days – production of new sperm
cells Estrogen Both Progesterone
 Vasodilating  Varicosity-  Constipation
o Ligation (BTL) effect: Hegar’s, weakening of  Vasoconstriction
 May equated to sterilization Chadwick’s vessels and effect
 Woman signs the consent but  Hormone that vasodilating  Salt losing
HUSBAND agrees to the procedure retains sodium; inc effects hormone
 Who should be present when MD blood volume  Hemorrhoids  Weakening of
discusses the procedure: BOTH the  Inc. in T4: gamma  Edema- primarily muscles
couple globulin estrogen but  Inc activity of
 After delivery- Best time to perform  Genital changes; later on ducts; secretary
because uterus is found in the growth of breasts, progesterone function
abdominal cavity hypertrophy of the (too much salt  Decreased clotting
 Easier to access the fallopian gums was lost  factors
tube  Skin changes- stimulation of  Weakens the
 Laparoscopic- introduction of air  stimulate RAAS-- > increase vessel walls
at risk for air embolism melanocyte sodium  Affects the mood;
 A 3 cm abdominal incision is made  stimulating  Breast changes- neuroendocrine
through which the tubes are hormone  skin primarily effect on behavior
tied/cauterized/cut changes estrogen
 Interval mini-lap – done during  Decrease o Progesterone-
the first 7 days of the peripheral changes in the
menstrual cycle vascular breast
 Post-partum mini-lap – done resistance
within the first 8 weeks after a
normal delivery Neither
*For DM patient  Waddling Gait-Relaxin- hormone from ovary
 Unsafe ang pills  affects insulin o In mobility of the joints, abnormal gait of
 Use barrier pregnancy
 Contraindicated to  Morning sickness- Hcg
o DVT
o Pregnant Gravida- pregnancy
o Thromboembolic disorders Para - delivered - must be considered viable- greater than 20 weeks
o Liver disease Term - 38 -40 weeks
o Coronary artery disease Preterm - 20-37 weeks
o Breastfeeding Abortion - below 20 weeks
 Don’t use pills that contain estrogen Living - living as of now
(depo-provera is OK) Multiple pregnancies – G,P,T counted as one, only in L is counted
 Estrogen shuts down prolactin Ectopic - counted in gravida and abortion
o Heavy cigarette smoking Stillbirth - Not counted in H
Hmole - Counted in gravida not in para
PREGNANCY GP TAL (6 DIGIT DISTRIBUTION)
G TAL (5 DIGIT DISTRIBUTION)
Heartburn – pyrosis Suspecting of pregnancy - considered as pregnancy
Chloasma – face-mask of pregnancy Segundi-2
Melasma – other parts – areola, linea nigra, axilla, groin Grand multi-5 and above
Striae – Due to separation of underlying connective tissue
Striae gravidarum – dark Leopold’s Maneuver
Striae albicantes – white  Systematic palpation of the pregnant women’s abdomen
Goodell’s sign – Cervical change to determine several data
 Explain what you will do to the pregnant women
Presumptive  To make sure that the results are accurate- tell the patient
 Subjective data to void
 Patient complaints  Position: Dorsal recumbent
 Leucorrhea, pica, pyrosis, morning sickness, quickening,  Draping Procedure: horizontal
urinary frequency, constipation  Warm hands before palpation; Cold hands stimulate
Probable uterine contraction
 Objective  When to do Leopold’s Maneuver: can be done at 5
months but best at 7-9 months
 L1

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 Maternal and Child Nursing
o Part of the fetus located at the fundus: cephalic
or breech
 Soft angulated, nonballotable –
buttocks
 Hard, round, ballotable - head
 L2
o Flat plain (back), nodular/irregular several
masses (fetal parts)
o Fetal lie/ Fetal back
o Longitudinal and transverse
 Long axis of fetus and mother
 Location of fetal heart
 L3
o Engagement
 If floating, not engaged
 If not floating and fixed, engaged
o Presentation: Head, buttocks, shoulder
 L4
o Fetal habitus/Attitude – occiput is the indication
of position
 A relationship of the baby’s parts to
each other; degree of flexion
 Flexion- normal attitude
 Extension
 Sincciput- head and hand
presented
o Position
 Face the foot part  place her fingers 2 inches above the
inguinal are  glide downward  find the occiput
 Nonballotable mass- buttocks
Pregnancy
Fertilization
 Union of a matured ovum and sperm
 Each gamete has a haploid number of chromosomes
 The sperm carries and X or Y sex chromosome
 22 pairs- autosomes
o Genotype – genetic material
o Phenotype – physical trait
 1 pair- sex chromosomes; determinant of sex
o XXY – Klinefelter’s Syntrome; male and female
o XO – Turner’s Syndrome – no development of
female sex characeristics
 Zygote- outcome of fertilization
 Father determines sex of the child
 Fertilization- sex of the baby is determined
 2nd month or 8th week- formation of genitals
 12th week- differentiated
 (4th month) After 12th week- ultrasound to establish the
baby’s sex
 Y sperm - Move really fast but die fast
 X sperm - Slow but sure
 Zygote mitosis blastomeremorula (round, mulberry in
shape, found at the end of the fallopian tube)  enters
the uterus  blastocyst  (ready to implant)  inner and
outer portion
o Embryoblast
 Inner
 Fetal portion
o Trophoblast
 Outer will become placenta and fetal
membranes
 Amnion- fetal membrane
 Chorion- placental portion
 Decidua
o Basalis
 Basalis
 Placental portion
o Vera
University of Santo Tomas – College of Nursing / JSV
o encapsularis
 Placenta
o Protective barrier
 Cytotrophoblast and
syncitiotrophoblast
 Present
 Prevents crossing of
treponemapallidum
 2nd trimester- syncitiotrophoblast
remains only
o Organ of the baby in utero
 Normal temperature of baby in utero:
25-28⁰C
 Endocrine/Metabolic activities –
provides hormones of pregnancy –
E,P,Hcg, hPL (fetal growth hormone)
 Transport function – nutrients,m stores
iron for 6 months
 Endocrine function
 Immunologic – IgG from mother at 34
weeks (9 months, passive natural
immunity, all diseases)
 Milk have IgA; protection from
diarrheal diseases
 Protective barrier against harmful
substances (drugs and microorganisms)
However, viruses may enter
 Give only tetanus toxoid
 Oxygenation
 Excretory organ
 Wastes by baby excreted by
maternal liver and kidney
 Umbilical arteries – waste
products
 Umbilical vein – oxygenated
blood
o Result of the union of the chorion and the
decidua basalis
o Chorion - source of the primary villi
o Chorion chorionic villi  release enzymes 
attach to maternal vessel and get blood 
blood goes to space called lacunae (blood
lake)  several lacunae will form  cotyledon 
more cotyledon will form placenta (15-20
cotyledons)
o 1 week after fertilization (after implantation)-
Start of placental formation
o 3rd week- circulation starts
o 3rd lunar month- complete its formation
o Grows until 20 weeks covering about ½ of the
internal surface of the uterus
o Corpus luteum
 Kept alive by hCG
 Maintain the endometrium to nourish
the baby
o HCG will rise up to the 3rd month
 Prevents involution of the corpus luteum
 Basis for pregnancy tests
 Present in maternal blood 8-10 days
after fertilization (as soon as
implantation occurs)
 Level doubles every 2 days
 Nauseated  morning sickness
 3rd month, placenta takes over E and P
 decrease hCG  degeneration of
corpus luteum; morning sickness
subsides
 Maternal and Child Nursing
 Hyperemesis Gravidarum
o Excessive vomiting beyond 1st trimester
o Can be seen in H-mole
o Pernicious vomiting – interferes with eating
 Vomits without food intake
 Metabolic alkalosis
 Ectopic Pregnancy
o Level of hCG will not increase above 3 months
o Management:
 Methotrexate- stop development of
cells
 Completed if hCG levels will decrease
 Abortion
o Normal hCG then it dropped – assessed through
serum hCG
 H-mole
o Fertilization of an empty ovum
o Only placental portion is forming (chorion)
o No amnion
o Human Chorionic Gonadotropin
 Establish pregnancy through urine
o 7th or 8th week- presence of gestational without a
baby
o Ultrasound at 1st trimester
 Pregnancy testing
o She missed her period today, when can she take
the test: TODAY
o Done in the morning
o First void
o Midstream collection
o Done again a week later if negative at first
 IgG- 2 weeks before delivery passed to baby
 Heparin- safe for pregnancy
o Cannot cross placenta
 Coumadin- can cross placenta
 Anything that happens to the placenta facts the baby
 You save the placenta until the MD orders it to be
disposed
Placental Aging Theory
 When the placenta degenerates  stimulation of labor
 Ultrasound- determines the placental age
o By the amount of calcification or amount of are
that is calcified
o Grade 3- fully matured placenta (38-40 weeks)
o Placenta premature degeneration
 Blood going to the placenta is
decreased  placenta degenerates
o 42 weeks- maximum weeks the baby can stay at
the placenta
Umbilical Cord
 length of the cord is estimated to be the same length as
the baby
 50-55cm (48-52 for Filipinos)
 Short- might develop abruption placenta
 Long- at risk for cord coiling
 Haase’s rule
o 1-5 months = Month2
o 6-10 months = Month x 5
 A-V-A
 Vein carries the 02 blood (placenta to baby)
 Arteries (baby to placenta)
 Wharton’s Jelly
o Fluid filled connective tissue to connect the baby
to the placenta
o It has fluid to prevent compression of arteries and
vein in the umbilical cord
University of Santo Tomas – College of Nursing / JSV
 Cord Prolapse
o Concealed – inside the vagina; elevate the hip
o Apparent – outside the vagina
o Baby is not yet engaged
o Gold Standard Answer: CHECK THE FETAL HEART
o Ask mother to lie down  check baby’s heart
rate
o Insert a gloved finger into the mother’s vagina to
check for cord prolapse
o Position mother to knee chest
o Trendelenburg is not advisable  compression of
diaphragm
o Left side lying- put pillows on the hip to elevate it
o Apparent
 Never reposition the cord 
compressed more
 Make sure cord will not shrink
 Cover with sterile gauze with warm NSS
to vasodilate and prevent atrophy
 Continuous irrigation
 CS- only means of delivery
o Emergency Situation
 A clean cloth is OK
Amniotic Sac and Amniotic Fluid
 Functions
o Cushions fetus against mechanical injury
o Maintains a steady temperature in utero (most
important)
o Allows freedom of movement -> change in
position of fetus -> musculoskeletal development
 16-18- multipara
 18-20- primipara
o Prevents drying of skin
o Permits symmetrical growth of the baby
o Prevents adherence to the amnion of the fetus
o Source of oral fluid for fetus; of 1000ml, 400 will
remain, 600 recycled
o Excretion – collection system
 Kidney’s start making urine around the 2nd-3rd month
 Continuously produced by amnion and fetal urine
 4th month- increased production because of fully matured
kidneys
o Quickening = enough amount of fluid
 Primi – 5 months
 Multi 4 months
 98% H20 and 2% Salt
 800-1000 ml- normal volume of amniotic fluid
 600ml is recycled, 400ml remain
 7-7.25 – pH (alkaline)
 Oligohydramnios
o Less than 400 ml
o Decreased urine production
 1 kidney (anomaly); Very small kidneys
 Suggestive of Down’s syndrome
 Polyhydramnios
o Greater than 2000 ml
o Decreased capability to swallow
(Tracheoesophageal atresia)
o Diabetic frequently
o Multiple pregnancy
 Color
o Slightly yellow in color, cloudy
o Not deep yellow- bilirubin mixed in the fluid
 Erythroblastosis fetalis
 Xanthochromic – RH incompatibility;
yellow fluid
 Maternal and Child Nursing
o Deep yellow – bilirubin staining – Rh
Incompatibility
o Pink/Red wine color – abruption placenta
o Green tinged- meconium stained
 Needs suctioning to prevent aspiration
pneumonia
 May cause lung collapse
 Because of fetal distress (cephalic)
 CS- management
 Fluid is also swallowed by the
baby
 Suctioning
 Because of breech presentation
(normal)
 Abdomen descends 
increase pressure 
defecation of meconium
o Red wine - mixed with blood
 Abruptio placenta
 CS- management
 Nitrazine Test
o Lithmus paper test
o Blue- positive rupture of membrane
 Premature Rupture of Membrane
o No option to continue the pregnancy  might
lead to chorio-amnionitis
o Fatal
o Infection of mother and baby
o Leaking fluid from the vagina
o Management
 IV antibiotics
 CS
o Preterm premature rupture of membrane
 Not in labor yet + pre-term baby
 Early Rupture
o Membrane ruptured before transitional phase
o Latent period- 3cm dilation
o Active- 4-7 cm
o Transitional- 8-10m
o Cod Prolapse
o May cause Infection and caput succedanum
o Best time for rupture: during transitional labor
o Prolonged Labor
 Pressure exerted from the placenta
helps the cervix dilate
 Will cleanse the vaginal wall
o Dry Labor
 Amniotic fluid makes the vagina more
slippery
 Management: use KY jelly
o Nursing care:
 Check FHT – if abnormal = left side lying
position
 Rupture without prolapse = check
temperature frequently – q20
 Anticipate antibiotic treatment and
possible oxytocin augmentation to
enhance contraction to decrease
length of labor.
 Ballottement
o Insert gloved fingers into the vagina  tap the
cervix  bouncing movement of baby
FETAL DEVELOPMENT
- Zygote – first 2 weeks
- Embryo – 3 to 8th week
o Period of organogenesis
- Fetus – after the 8th week until delivery
o Period of rapid growth
University of Santo Tomas – College of Nursing / JSV
- Social drugs – cross addition; withdrawal symptom; get 1st
urine sampling
- Smoking – SGA due to vasoconstriction
- Thallidomide (antiemetic) – phocomelia
- Lithium, Streptomycin,Kanamycin – damage to 8th cranial
nerve: deafness
- Tetracycline – staining of permanent teeth of baby
- Valium – can lead to cleft palate defect
Intrauterine development
 Pre-embryonic
o Ovum zygote embro
o 0-2nd week
 Embryonic
o 3-8th week
o Important period
 Organogenesis
 Fetal
o 8th week onward
 2 weeks- heart (beats on the 25th day)
 3 weeks- brain/CNS development (B9/folic Acid, glucose)
 2 months
o Separation of GI and respiratory tract
o Sex organ develops
o Meconium in the intestine
o Respiratory structure are not yet formed
 Rubella- most dangerous
o Can damage structures of the baby developing
at that time
o Underdeveloped structures (microcephaly,
glaucoma, cataract, defect in 8th cranial nerve,
mental retardation)
o 1-3 months- 60% chance of damage
o 4th month- 10% chance
 5th month- no chance of harming the
baby
o Vaccine NOT safe to be given  give
GAMMAGLOBULIN
o After deliverycan have vaccine
 Cannot get pregnant for 3 months
 Chicken Pox
o Women in the first 7 months of pregnancy have
a very high immunity for chicken pox
o After the 7th month (last trimester)  at risk for
chicken pox
o If with chicken pox during delivery, after
delivering the baby separate first mother and
baby to prevent transmission
o Can have chicken pox vaccine after delivery
but cant get pregnant for 1 month
 3rd month (fetal period)
o Growth in size and weight
o Sex is well differentiated
o Ossification- bone formation and development
 Increase intake of calcium
 800 mg (2 servings) – 2 glasses of milk +
400 mg for the baby
 If decreased calcium intake  baby
will get calcium from mother’s bones 
decreased bone integrity of the mother
 loses her teeth
o Sources of calcium
 Dairy
 Green leafy vegetables
 Fish bone (sardines)
 Egg yolk (2 eggs per week)
o End of the 3rd month: ideal time from UTZ
 Maternal and Child Nursing
 Genetic testing (early part of
 4th month pregnancy)
o Amniotic fluid is recycled as urine  Hemolytic Diseases (middle)
o Quickening  Pulmonary Maturity (late) – L:S ratio
o Vernix/Lanugo  Sex
o Can do amniocentesis o Alpha-feto protein (early)
 Enzyme only elevated when there is a
 5th month break in the neural tube
o Fetal heart rate  Spina bifida
 Can be heard as early as 3 months  Elevated- Spina bifida (neural tube
(Doppler) defect)
 4th month (fetoscope)  Very low- Down syndrome
 4-5th month (steth)  Can get from maternal serum
 120-160 bpm (maternal serum alpha-feto protein)
o Quickening (Primi: 18-20 weeks; multi: 16-18  Good result but not
weeks) conclusive
o Ballottement  Only a screening test
 From amniotic fluid = direct result, done
 6 month if maternal AFP shows abnormal values.
o Regular sleep wake cycle  98% percent tested positive result but
 Neurological functioning has began only 1% is with defect
 20 hours a day o Hemolytic Disease
 Awake- at night (hungry); at morning  Color of amniotic fluid
when mother eats (30 minutes; increase o Pulmonary Maturity (organ maturity)
supply of glucose to baby)  Check baby’s lung maturity and kidney
 Fetal movement count function
 First movement is the start of  High level of creatinine- kidneys are
the time functioning
 10-12 movements/hour  High level of bilirubin- liver problems
(Cardiff Protocol) o Done first with ultrasound: FULL BLADDER
 Must eat first before counting o Amniocentesis: EMPTY BLADDER
 Empower mother to know the o MOST IMPORTANT: Check signed consent
condition of the baby o What will the nurse prepare before
 Less than 4 movements in 24 amniocentesis: ultrasound
hours- danger sign; do o Abdominal- full bladder (more common) 1 ½-2
biophysical scoring glasses of water
o Non Stress Test o Vaginal ultrasound- empty bladder
o Ultrasound o After obtaining ultrasound  empty bladder to
o Vernix caseosa – for temp regulation facilitate amniocentesis
 7th month o Sterilize area  use sterile needle
o alveoli opens (surfactants are present) – start of o Use local infiltration
lung maturity o 5-10ml is aspirated
o No surfactant o Aspirate; should not be exposed to direct light
o Fat deposits under the skin o Area of puncture should have adhesive
o Weight is doubled o Position on her back but not flat (semi-fowlers)
o Red and plethoric  Pillow on right side – Right lateral tilt
 8th month  Because uterus could go to
the left and cause vena cava
AOG L/S Ratio Lung Maturity compression
26-27 Secretion into alveolar Viability o BP and FHT q30
wks space begins attained o Normal side effect
 Slight leaking of fluid in the area of
30-32 1:2:1
puncture
wks
 Baby moves more frequently than
35 wks 2:1 Maturity normal
attained  Slightly increase in fetal heart rate
 BP of mother slightly increased
oPhosphatidyl glycerol  For 2 hours only
 Phospholipid only noted when the fetal  Greater than 2 hours- admit to
lungs are mature (most important and hospital
best indicator) o Abnormal Side effect:
 Amniocentesis  Leaking fluid from the vagina 
o Test to establish lung maturity and maturity of premature rupture of membrane; early
other organs labor – check for pH (REFER)
o Not a routine procedure – performed on 2nd  Abortion 1;200 (early)
trimester  Early labor (late)
o Invasive, needs written consent, UTZ guided.
o Can lead to possible abortion
o Gives information on fetal:

University of Santo Tomas – College of Nursing / JSV

 Maternal and Child Nursing
Determining EDC o Pre-colostrum
- If known LMP, use Nagel’s Rule = -3 +7 +1  Present at 4th month (16th week)
- If not known, use Bartholomew’s Rule – abdomen is  Not the real milk but a precursor of milk
divided into quadrants  Yellow
- McDonald’s Rule – get the fundic height (cm) x 8/7 = AOG  How many days will it take to empty the
in weeks breast of colostrum: at least 3 days for
- Kung ano yung sa situation, yun yung AOG. multipara
- DO not get the lower number  Up to 5 days for primipara
o Immediately after delivery  put the baby on
Johnson’s Rule – Fh (cm) – n x 155 = g. the breast (without airway obstruction)
- N = 11 – if the part is not engaged o CS- slightly delayed breastfeeding (4 hours after
- N = 12 – if the part is engaged pa pwede)
o Wear bra support
Maternal Changes during Pregnancy  Strap supports
 Head o Nursing Bra
o Hair- grows faster and longer  Thick strap
 Stimulated by estrogen  With opening for easier breastfeeding
 Old hair that is growing fast  Abdomen
 6 months postpartum- lose old hair o Darkening of the LiniaNigra
 Don’t use hair treatments  goes to the o Abdominal Striae (stretch marks)
baby  Gravidarum- dark brown
 Chloasma  Albicantes- whitish
o Bony prominences exposed to the sun  Postpartum
o Mask of pregnancy o Diastasis Recti Abdominis
o Freckles  Overstretching of the rectus abdominis
o Dark people - darker areas are on the creases muscle
o Only temporary  Abdominal exercise up to 5 months
 Melasma  Beyond 4 months- left side lying position
o Other parts darkens o Bartholomew’s rule of 4
o Not noticeable in multipara  Determine age gestation fundic height
 Nose  5 months- umbilicus
o Nasal congestion  Lightening- lowering of the uterus
 Increased vascularity  Engagement- lowering of the head of
 At risk for epistaxis, advise to open the baby
mouth o McDonald’s rule
 Gums  Using tape measure to get fundic
o Hypertrophied height in cm x 8 / 7
 Use soft-bristled toothbrush  = AOG in weeks
o Advise to check-up with dentist  Yung given na cm, malapit dun yung
o At risk for losing teeth  can never have tooth aog
extraction because of anesthesia  Usually higher
o Pagnatanggalanng teeth strep might go inside o LMP
gums teratogenic  Jan-march
o Increased salivation  G
 Chew fruits  April-Dec
 More acidic  -3 +7 +1
 Tooth erosion  Vagina
 Frequent use of mouth o Mucus plug- operculum
 Decrease bacteria in the o Less acidic- more prone to infection
mouth  Legs
o Edema
 Pica  Poor venous return (too much pressure
o Craving for nonfood or nonnourishing food on the lower part of the body)
o Decreased nutrition for the baby  Low salt diet
o Provide protein to the diet  Management:
o Treatment for anemia  Elevate- up to 3 pillows
o Nonfood  Edema on nondependent areas is
 Clay abnormal
 Charcoal  Lower lid and fingers (+3)
 Toothpaste o Weight gain
o Chemical mother ingest can be dangerous for  1-3 months- 1 lb. per month
the baby  4th month and above- 1 lb per week
o Refer to psych  Filipino: up to 12 kgs or 25 lbs
o Varicosity
 Breast  Due to weakening of the blood vessels
o Enlarges and vasodilation
 Estrogen stimulates ductile structures  Pressure of the uterus
 Progesterone stimulates secretory  Avoid prolonged sitting or standing
gland of the breast  Elevate with pillows (up to 2)

University of Santo Tomas – College of Nursing / JSV

 Maternal and Child Nursing
o Vulvar varicosity
 Put pillow on hips to elevate
 To decease risk of rupture  put
sanitary pad (at least 1 layer)
o Sexual Activity
 Safe during pregnancy
 Don’t do nipple stimulation during
foreplay  stimulation of oxytocin
 No oral-genital stimulation (not to blow
air inside the vagina) pressure is
introduced  can rupture and open up
the vessel  air embolism
 No douching  air embolism
o Cramps
 Calcium-phosphorus imbalance
 Lightening and engagement pressure
on the sciatic nerve  cramps
 No prevention
 Just stretch and dorsiflex the
foot
 No massage (might dislodge thrombus)
 Stretch and dorsiflex the foot (safest)
 Place warm compress only if there is no
varicosity
 Scenario: foot is on the stirrups 
cramps  take the leg off the stirrups
then dorsiflex
 Scenario: crowning of the baby  keep
leg on the stirrups dorsiflex the foot
o Relaxation of smooth vessel walls causes
increased tendency for varicosities
 Stockings: best to prevent venous
dilation (but is not always the answer,
depends on the situation)
 Sit every 2 hours, stand up and walk for
15 minutes
 Nutrition
o Pregnant: 1700, Additional 300 calories
o Breastfeeding: additional 500 cal, addt’l protein
SYSTEMIC EFFECTS OF PREGNANCY
Cardiovascular
 Sudden increase in blood volume
o 45-50% (plasma only) – because of increased fetal
demand
o Up 30% during 2nd trimester, and up 50% during 3rd
trimester
 With iron treatment - Can increase cellular
component by 30%
 No iron treatment - 10%
 Iron treatment - 2nd trimester to prevent
deficiency in 3rd trimester
 Sources of iron: Organ meats, dark colored
preserved fruits (raisins), green leafy
vegetables
 Iron supplement
o Best taken with empty stomach
(acidic)
o With meals + foods high in citric
acid
 Prone to infection
 Easy fatigability, shortness of breath,
palpitation
 Exercise:
 Whatever she did before is safe
except contact sports
University of Santo Tomas – College of Nursing / JSV
 No weights greater than 5lbs may
cause valsalva maneuver
 No sauna – teratogenic if too
much heat
 Floor exercise such as curl ups =
side lying on the left
 Pelvic rocking and tailor sitting for
backache
 NO CONTACT SPORTS
o Decreased hematocrit- physiologic or pseudoanemia
o Cardiac rate- increased by 10 beats per minute
o Increased WBC
 Slight elevation
 Not a significant sign
 Significant if accompanied by other
symptoms of infection
 Increased coagulation
 BP decrease during the second trimester, return to normal
during the 3rd
o Vasodilation due to estrogen – PIH at 20-24 wks
o HR increases by 10 BPM on 2nd trimester
 Advised pregnant woman to wear seat belt, no driving
pag 7 months na
 Traveling by plane is not safe in the last trimester
 Boat rides not safe during 1st trimester
 Iron deficiency anemia:
o Mother provides baby’s requirements
o Baby stores Iron for 6 months
Uterus
 As uterus grows in size goes into the abdomen 
woman lying on back  uterus pushed to the right side 
pressure on vena cava uteroplacental insufficiency 
fetal heart (distressed)
 Shape changes from pear to oval shape
 Rises out of the pelvic cavity by the tenth week
 Non-pregnant uterus- needs 15 ml/min of blood
 Pregnant uterus- 500ml/min
 Upright- uterus will find a space in the abdomen
o Side sitting and side lying safe
 Raising right part paramatiltyug left  prevent
hypotension
 Angiotensin gene T235- will not allow you to respond to
estrogen normally (afro-americans)
Pregnancy-Induced Hypertension
 At risk for PIH:
o Old
o Smoker
o With T235 gene
 Test:
o Roll over position
 One on flat and one od side lying
 Get BP
 >20 diastolic – (+) hypertension
Respiratory System
 Inc CO2 level > effect of progesterone and fetal waste –
effect depends on patient
 TEATMENT OF CHOICE IN ASTHMATIC PREGNANT: B-
adrenergic agonist – Bricanyl – same drug used in
premature labor, tocolytic
o Risk for arrhythmia – use beta blocker; Propanolol
o Any steroid is not safe during pregnancy!
 Prone to hyperventilation = deep breathing
o Blow through a brown bag or cupped hand
 Nasal congestion
 Difficulty of breathing
 Maternal and Child Nursing
Renal System  First trimester due to increased hcg
 Pressure on the bladder (first and third tri) >  Cravings/increased appetite
 Inc renal perfusion > Increased glomerular filtration rate >  Smooth muscle relaxation (Progesterone) >
inc output (low specific gravity) decreased peristalsis
 Glucose threshold drops (due to progesterone)and more  Heartburn or Pyrosis
glucose likely to be expelled thru kidneys thus will see an o Eat slowly (chew 10 times before
increase in insulin demand after 24th week swallowing)
 To check for GDM – use serum glucose because urine will o Eat small frequent feedings (especially in the
always have glucose during pregnancy last trimester)
 Enlarging of the uterus add pressure to the bladder o Avoid fats and spices
o Frequency o Fiber should be cooked
 Beginning of pregnancy because of o Can be given antacids
pressure to the bladder  Aluminum magnesium
 Later during the lightening because of combination
the descend of the uterus  Prevent GI complaints
o Urgency  Maalox - only antacid that is lowest
 If there is discomfort  possible UTI irritable bladder sodium
syndrome  premature labor  Abdominal cramps
 Aldosterone production increases  Decreased peristalsis due to progesterone
o Increase in sodium and fluid retention o Gas constipation
 If with kidney failure o Heartburn
o Both can be used as long it is consistently  Constipation and gas
monitored because both are at risk o Never laxatives since it will stimulate the
 Urine sample is good within 2 hours uterus to contract
 Benedict’s test – for glucose in the urine – blue is negative o No oil based preparation since it hinders fat
(-) soluble vitamin absorption
 Heat and Acetic acid test o Stool softeners are ok (Colace)
o Get urine 2/3 full  heat  Morning Sickness
 If clear- ok o Phenomena only in the morning
 If cloudy  put acetic acid  hCG
 If clear- possibly due to increased  Because of Hypoglycemia (baby
protein intake the day before used up all her glucose
 If cloudy  albumin determination  Eat crackers before getting out of
(24 hour urine collection) bed
 N/V (hyperemesis)
Musculoskeletal o Pernicious vomiting
 Changes ion center of gravity as pregnancy progresses  Vomiting that ffects food intake
 Lordosis - back pain – pride of pregnancy  All throughout the day
 Prevent back pain  Met.Alkalosis
o Maintain postural alignment of the spine o Persistent vomiting
 Sit on the floor (tailor sitting position)  Exceeds first trimester
(Indian sitting) o Starvation vomiting
 If with back pain: Pelvic rocking position  Met.acidosis
 Cramping in calf from hypocalcemia or hypercalcemia o Causes
 Progressive softening of the cartilage  H-mole – remove the mole
 Waddling Gait (inc mobility of pelvic joints) due to  Psychological cause - Level of
RELAXIN form ovary maturity should be assessed
 Walking – assisted  AGE IS IMPORTANT
 For back pain – do pelvic rocking exercises FACTOR
 Shoes o Cracker-water combination
o Any shoes that are low heeled  Give cracker, wait for an hour, if
o Wedge ok, give sips of water, the if ok
o Rubberized repeat every hour
 Can they use bath tub: yes o 2 days NPO 3rd day water-cracker  soft
o Somebody should assist her in getting in and out diet  full diet
of the tub
o Should be rubberized Endocrine
 1st trimester – no boat ride because of nausea/vomiting  Anterior pituitary gland:
 3rd trimester – no airplane since change in pressure may sti o decreased FSH
contraction o ncreased LSH
 Safest: Automobile, must ambulate every 2 hours for o Increased oxytocin secretion during labor and
circulation for 15 mins delivery
 Ovaries secrete relaxin
Neurological o Increased flexibility of joints
 Pressure on the sciatic nerve in third trimester  Increased thyroid hormone, thyroxine (T4)
o Cramps o Increased BMR
Gastrointestinal  Increased demand for insulin from pancreas
 Bleeding gums  Production of relaxin
 N/V

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 Maternal and Child Nursing
o Hormone that permits relaxation of hip joints in  Late abortion- after 16 weeks AOG
preparation for child birth o More dangerous
 PTU o Possible DIC
o low dose – safe during pregnancy  Spontaneous Abortion
o high dose – dwarfism and cretinism o Also known as miscarriage; 15-30% of
 Hyperthyroidism may lead to thyroid crisis and abortion
hypothyroidism may cause infertility.  Chromosomal abnormality
Psychosocial Task  Infection that damages organs of the
 Maturational Crisis baby
 Situational Crisis  Endocrine disturbance (Hyperthyroid)
 First Trimester  Trauma
o Period of ambivalence  Incompetent cervix – dilates w/o
o TASK: Acceptance of pregnancy (assess uterine contraction
maternal feelings, support)  Induced Abortion/Therapeutic
 Second Trimester o Performed to save the mother
o Acceptance and fantasy o Ectopic pregnancy
o Fantasy about the baby  Habitual Abortion - 3 consecutive times or more abortions
o Might have an ideal child in her head  might  Incomplete Abortion
have a different child o Fetus is expelled
o o Placenta retained
o TASK: Fetal Embodiment (accepting the baby as o Management- D&C, suction curretage
separate from self  Complete Abortion
 Last Trimester o All products of conception expelled
o Fear of delivery o Mgt: methergine, antibiotic (pennicillins),
o TASK: Preparing for child birth or fetal separation pain meds (mefenamic)
 Introduce childbirth classes  Threatened Abortion
 Lamaze – psychoprophylaxis o Painless spotting with not effect on fetus
(conditioned response) o 2 weeks rest: Complete bed rest; soft diet
 Bradley – natural childbirth; husband given sedatives to prevent stimulus for
coached; no medication; oxytocin contractions; sex resume after 2 weeks
released through nipple stimulation  Missed Abortion
 Dick Read - hypnosis o Fetus dies in utero and is retained
 Fatherhood o No caesarean section
o Mittleiden- “to hatch” observes behaviors and o Drugs to contract the uterus
“taboos” associated with pregnancy o Laminaria – dried seaweed that is sterilized,
o Couvade- means “suffering along” absorb the fluids, expand and painlessly
 Psychosomatic symptoms felt by the expand, then given misoprostol (Cytotec)
husband while the woman is free from intravaginally and Oxytocin (Pitocin) per IV
the same o D&C to remove the placenta
 Toddler
o Relay news of pregnancy when there are signs  Signs and Symptoms:
of pregnancy o Threatened Abortion- cervix is still closed
 School Age and Adolescent  Vaginal bleeding/spotting
o Relay the news as soon as pregnancy is  Painless
confirmed o Inevitable/ Imminent
 Fetus and clot expelled
High Risk Factors  Vaginal bleeding may be heavy, pain
- Age = 18 and below; 35 and above on abdominal area and radiates to the
- Height = 4’10 back
- Weight – less or more than 20% of ideal body weight  Contractions
- Parity = Primi; G5 above  Cervix dilated
- Nutrition deficiency: CHON deficiency  Management
- Low socioeconomic level o Complete bed rest
History o Soft diet: Prevent constipation  prevent
- Medical = DM, HPN, Heart disease straining
- Gyne: STI, infertility o Sedatives - stress can predispose the
- Surgery: abdominal abortion of baby
- OB: Bleeding, PIH o Admission in hospital only for observation
to observe for further bleeding
o Cerclage
BLEEDING COMPLICATIONS  McDonald’s- temporary (12-14 weeks)
(NSD)
First Trimester Second Trimester Third Trimester  Shirodkar-bar- permanent
Ectopic H mole Placenta previa  Purse String
Abortion Abruptio placenta  Delivery by CS
o D&C
Abortion  Safe all the tissue that passes out for
 Loss of pregnancy before fetus is viable (<20 weeks) histopathology
 Early Abortion- before 16 weeks AOG

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 Maternal and Child Nursing
 Might scar endometrium possible
placenta previa on the next pregnancy
o Help cervix dilate (induction of Labor)
 Laminaria- seaweed introduced into
the cervix; will swell if absorbed water
cervical dilation
 Misoprostol (Cytotec)- prostaglandin
that increases blood supply to the
cervix (more dilatable)  softening of
the cervix
 Oxytocin (Pitocin/Syntocinon) -
contraction of uterus
 Dead baby can be expelled
 Placenta removed through D&C
 Possible DIC to mother
 Home Management
o Restriction at home for 2 weeks
o Can have sex after 2 weeks
o Can go back to work after 2 weeks
 50% of threatened abortions lose their babies
 Causes
o Genetic defect in the baby
o Endocrine factors
 Hyperthyroidism
 DM (rare)
o Infection
o Systemic disorders
o Psychological factors
 Medications can be terratogenic
o Incompetent cervix
 Can be managed surgically
 Dilates without uterine contraction
 Frequent dilation- D and C
 Habitual Abortion
 Complication: Missed Abortion - DIC
 Classical CS incision - forever CS
Medical Therapeutic for Spontaneous Abortion
1. Ultrasound
2. Bed rest
3. Intravenous fluids
4. Possible blood transfustions
5. D&C
6. RhoGAM given within 72 hours post-delivery, post
amniocentesis and after D&C
ECTOPIC PREGNANCY
 Pregnancy outside the uterus
 Sites
o Fallopian
 If in isthmus - more bloody (closer to
uterus); can be expelled vaginally
 70% tubal
 If in ampulla- chronic bleeding (more
dangerous)
 Acute – on the isthmus;
bleeding form rupture may go
to the uterus and manifest
outside
 Chronic – on the ampulla;
bleeding form rupture goes
back and goes to the cul-de-
sac (Cullen’s Sign)
o May compress
phrenic nerve;
shoulder pain upon
respiration; same
side with ruptured
University of Santo Tomas – College of Nursing / JSV
o May go to shock
o Manifestations
 Cullen’s Sign
 Bluish discoloration in the
umbilicus – hematoma
because of the bleeding
underneath the peritoneum
 Cul-de-sac mass
 Normally it is hollow
 Shoulder pain
 Referred pain
 Compression of the phrenic
nerve
 Side of implantation
 Unilateral, lower quadrant, on and of
colicky pain (not ruptured), sharp one-
sided pain (rupture)
o Ovarian Ectopic
 Rhythmic contractions of the fallopian
tube pushes the zygote backward to
the ovary
o Cervical Ectopic
 Hypermotility of the zygote then
implants itself in the cervix - IUD
 Cervix has low blood supply  cannot
fully nourish the baby
 Remove the portion of with the fetus
then cerclage is done
o Abdominal
 Laparotomy done to get the baby
 Placenta is retained in the attached
organ
 Will naturally degenerated
 Medical Treatment for Ectopic Pregnancy
o Administration of methotrexate IM (prevent
multiplication)
o Surgical treatment – salphingostomy via
laparoscope
 Risk Factors:
o History of PID
o IUD
o Abnormal tube
o Endometriosis
 Abnormal thickening of the
endometrium due to hormonal
imbalance
 Estrogen
 Management- androgen (male
hormones)
 Can damage the liver
 Given Depo-provera
 40% of young women are at risk
HYATIDIFORM MOLE/MOLAR PREGNANCY
 Gestational trophoblastic disease - proliferation of the
trophoblasts (bigger than age of gestation); no
embryoblast
 Trophoblast > formation of amniotic fluid > elevated HCG
 Benign - precursor of choriocarcinoma (malignancy)
 Inc. FH, No FHT, hyperemesis, red or brownish vaginal
bleeding which may also include vesicles (diagnostic!)
 Degeneration of the chorion into the fluid-filled grape like
chorionic epithelioma
 NO KNOWN CAUSE
 Risk Factors
o Extremes of age - very young and very old
o Genetic - Asian women
o Low protein diet
 Maternal and Child Nursing
o Use of Clomid – stimulate excretion of egg cell  Double set-up: NSD and CS
that is empty (fertility drug)  Complication
 Manifestations o Bleeding because area of attachment (lower
o Increase in fundic height part of uterus) does not contract
o Increased hCG
o Hyperemesis ABRUPTIO PLACENTA
o No fetal heart tones  Sudden complete/partial separation of a normally
o Red, brown vaginal discharge implanted placenta after 20th weeks AOG
o Ultrasound reveals mass without fetal skeleton  OBSTETRIC EMERGENCY
 Snowstorm pattern  Risk Factors
 Management o HPN
o Suction evacuation of the mole o History of placental abruption
 hCG monitored after o Multipara
o Curettage - if she still wants to become pregnant o Substance Abuse
 Labs drawn – serial hCG monitoring  Types
(blood) o Partially or Completely Separate
 CXR – to establish if metastasis is seen o Concealed
 Birth control for minimum of one year  Separation at the middle
 If mole is cancerous – chemotherapy  More dangerous
(methotrexate)  Blood will not b able to come out  sink
o Hysterectomy into muscles  board-like rigidity
o Monitor level of hCG for 1 year after surgery (internal bleeding)
o Teach the patient to delay pregnancy for 1 year  Shultz, Couveaire
o Follow up for choriocarcinoma o Apparent – separation from marginal area
o Provide emotional support where blood mixes with amniotic fluid
o Methotrexate- drug of choice for
choriocarcinoma  Assessment
 Since it is folic acid antagonist, free o Sharp like abdominal pain
from folic acid diet since it will o Board-like abdominal pain (Couvelaire)
neutralize the effect o Changes in the shape of the uterus
o Chest x-ray o Usually w/ vaginal bleeding - Dark red (not fresh
 To determine if there was metastasis to blood)
another area o Middle of pad- scant
 Lungs- most lymphatic organ o Fully saturated pad- 30 ml of blood
o Use birth control (Combined birth control) o 1/3 pad- 10 ml
o S/Sx of shock fetal distress (bradycardia)
PLACENTA PREVIA o Assess abnormal coagulation
 Low lying placenta/ attachment in the lower uterine o 99% of babies die
segment
 Risk Factors
o Uterine abnormalities
o No invasive History of uterine surgery Environment is the priority, Nursing Interventions must
 Causes: primary be directed to the patient
o Unfavorable deciduas
o Multiparity  Management
o Twins (dizygotic/fraternal) – different placenta o Position on modified trendelenburg
 kung sino unang kumapit, sya yung  Blood from the extremity will go to more
nauna important organs
 Manifestations: Painless, bright red bleeding from the o Keep patient warm
placenta, soft uterus  Cover her with several layers of sheets
 Dx : Ultrasound o Monitor CVP
 Types  Right pressure of the heart
o Low lying - placenta is very near the cervix but  If increased- slow down the IVF to KVO
does not cover it o Fluid volume deficit
 May be NSD, may have minimal  Priority nursing intervention
bleeding, double set up when bleeding  Then altered perfusion
occurs
o Marginal - 1 cm before you touch the placenta Previa Abruptio
o Partial – placenta covers 50% of the cervical ox Low implantation Sudden separation
o Complete/Total - placenta covers the entire Bright red With or without bleeding
cervical O Painless Painful
 Excessive bright red bleeding with no Soft uterus Couvelaire uterus
pain, not in bleeding
 Directly CS Emergency Implementation for Bleeding in Pregnancy
 Management - Alert the health team to provide maximum coordination
o No IE in suspected previa of care
o treatments - Place woman on modified trendelenberg or left side lying
o Only through CS (partial and total) (minimal bleeding)
o NSD (marginal and low lying)

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 Maternal and Child Nursing
- Begin IV with a gauge 18-19 needle in anticipation of
blood infusion  Management
- NPO in anticipation of surgery o Mild
- Administer oxygen PRN at 2-4 L/min to provide adequate  Bed rest on left side
fetal oxygenation despite decreasing circulating volume  Diet alterations: High protein, low fat,
of blood low salt
- Assess blood loss (weigh pads), FHR, VS, I and O, Uterine  Normal CHO to avoid use of protein for
contractions energy
- Omit vaginal or rectal exam  Monitor fetal status – times two of
- Order type and cross match 2 “U” whole blood to restore normal visit
maternal circulating blood  Twice a week on the last
- Assist with placement of CVP (assess pressure of blood month
that goes to the heart) o Severe
Pulmonary wedge pressure (pressure that leaves the  Altered perfusion
heart)  Altered sensory and perceptual
o Rise in CVP – put to KVO function (priority) – promote quiet, non-
o Low in CVP – hasten delivery stimulating environment
- Set aside 5 ml of blood in a test tube and observe if it will  Room of patient is 20 feet
clot in 5 mins. If it did not clot, suspect DIC away from the nurses station
- Maintain a positive attitude towards fetal outcome to  Limit visitors to visiting time to
maintain bonding promote rest and sleep
 No TV and close eye work
Stages of fetal Death  High protein, low salt, low fat
 Macerated – Generalized softening of skin  Bed rest anticonvulsant medications
 Mummification – death-like  Fluid and electrolyte replacement
 Lithopedian – calficied bones  Corticosteroids are given:
bethamethasone
PREGNANCY INDUCED HYPERTENSION / TOXEMIA  Anti HTN meds

PIH Chronic HPN  Magnesium Sulfate (TL: 4-8 mg/dl)

Seen on 20-24 weeks
Accompanying symptoms
are hypertension, edema,
and proteinuria
Eclampsia - convulsions
BP will be normal after 6
weeks
 Noted in the second trimester
 Risk
o Primipara - highest
o Young and old
o (+) HPN in hypertension
o Low socioeconomic group
o Low protein diet
 Manifestation
o Edema – generalized anasarca
o Proteinuria
o HTN
o Has convulsion
 Corrected within 6 weeks after delivery
 Cause is unknown; due to hormonal change
 Stages
o Stage 1 (Pre-ecclampisia)
Mild (Home
Management)
BP 140/90
Edema of finger and face
Proteinuria +1 (<2g/day) –
less than 2 g of protein
per liter
Seen before 20 weeks  Anticonvulsant
No proteinuria  IM bolus, Buttocks, Deep IM, Z-
track
 Check DTR,RR, BP, FHR,
No convulsions I&O(released through the
BP will remain elevated kidneys; monitor I&O; maintain
after 6 weeks 30 ml before giving next dose)
before giving first dose
 Prepare calcium gluconate;
max of 8 hours
 May be replaced by
Hydralazine (vasodilator)
 Potassium sparing (non-
thiazine) because loss of
potassium can affect the
heart
 12 gms- respiratory distress
 >12 gms- circulatory collapse
 If IV- use soluset - over a
period of 20 minutes
 Stinging to the tissue -
lidocaine is added to
decrease pain
 Magnesium sulfate first before
lidocaine
Severe (Hospitalized)  Corticosteroids
BP 160/110 or above  Stimulates Surfactant
production for the baby
Anasarca – third spacing
 Given for possible preterm
edema
birth
Proteinuria + 3 or 4 (more
 Injection within 2 days before
than 2g/day)
birth
 Betamethasone – better but
Epigastric pain (aura)
expensive ( 2 injections)
Visual disturbances – inc  Dexamethasone – cheaper (4
ICP doses)
Altered sensory and
perceptual function

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 Maternal and Child Nursing
 Epigastric Pain (aura for seizure)
 Grand mal
 With loss of consciousness
 Tonic-clonic
o Delivery: CS
o Given epidural if NSD to anesthesize prevent
seizures
o Greatest risk for convulsion
 1st 24 hours after delivery because of
loss of fluid  increased BP to
compensate for the fluid loss
ECLAMPSIA
 Grand mal (generalized tonic clonic seizure w/ loss of
consciousness)
 Stages
o Invasion
 When VS is fluctuating, restless
o Aura (warning) – epigastric pain! (may signal
HELLPS – hemolysis, elevated liver enzymes (DIC),
decreased platelet)
 Protect the tongue
 Side-lying position (DO THIS FIRST!)
 Tongue depressor is NOT safe, use
mouth gag
 Tongue blade (rubber)
o Tonic-clonic / Contraction
 20 sec tonus (muscle contraction)
before clonus (alternate contraction
and relaxation)
 Prevent self-inflicted injuries: Time the
duration of seizure  to know how
much time brain lost oxygenation
 Lock jaw
 Prepare for safe environment; padded
side rails
 Do not restrain or stop
o Post-ictal
 Coma/Resuscitation
 Oxygen first before suction
 Reorient the client to prevent anxiety
which may cause another seizure
 Antianxiety medication (Valium)
*Status epilipticus – may cause death
 Nursing Care
o Mild preeclampsia
 Bed rest on the left side
 Diet alteration
 Monitor for fetal status
o Sever preeclampsia
 Bed rest
 Anticonvulsant medication
 Fluid and electrolyte replacement
 Corticosteroids are given:
bethamethasone to increase
surfactant production
 antiHPN meds
o Mgt: Forceps assisted, analgesia to prevent
stimulation
GESTATIONAL DIABETES
- Human placental lactogen (HPL) – counteract effect of
insulin
- Estrogen and progesterone – antagonist of insulin
- Placental insulinase – enhances degradation of insulin
- Placental insufficiency – Maternal insulin utilization
- Effect on baby
o Macrosomia – wide shoulders, fractured clavicle
University of Santo Tomas – College of Nursing / JSV
o Organomegaly – heart, liver
o Preterm delivery
o Hypoglycemia – due to hyperinsulinism inside the
mother
- Effect on mother
o More prone to infection; UTI – sugar is increase in
urine
o Greater incidence of PIH and eclampsia
o Inc incidence of hydramnios
o Distocia – CS management
o Atony of uterus after delivery - hemorrhage
 Dx:
o Not diagnosed in the 1st trimester
o Diagnosed in 2nd trimester- 5th month
o OGTT (glucose challenge)
 Ability to use glucose in the body
 Get FBS – baseline; if abnormal, patient
is diabetic
 Intake of 50 gms of oral glucose
 Check blood glucose 1 hour after
 <7.8mmol, 140 mg/dl or less
7.8 mmol of less - normal
 >7.8, 140- abnormal
 If abnormal, ingest 100 gms of oral
glucose
 Check blood glucose 3 times for every
hour
 2 positive- (+) for GDM
 Management
o Only INSULIN is given – 2nd trimester
 Later half of pregnancy more insulin
requirement
o No OHA
 Crosses placental barrier, teratogenic
 Further aggravate insulin production in
baby
o Insulin
 Last trimester (increased demand)
 Labor- will have insulin pump
 Postpartum- at risk for hypoglycemia
o Postpartum- 6 weeks, diabetes should resolve
 Diet: 6 meals- because of insulin to prevent hypoglycemia
o 200 calories additional in GDM, in normal 300cal
 45- CHO
 35- protein - delays absorption of
glucose
 20- fat
 Eat a light meal before exercising
 Returns to pre-pregnancy state after 6 months
CARDIAC DISEASES IN PREGNANCY
 3rd trimester- risk of CHF
 Decreased blood to the baby  premature by size and
age
 If employed, advise to be shifted at day shift best time to
sleep at night  during sleeping, increase growth
hormones
Effects of Pregnancy on a Client with Cardiac Disease
 Cardiac output increases by 30-50% CR increased by
10bmp
 Progesterone stimulates the respiratory center causing
dyspnea
 Increase blood volume may precipitate CHF
Classes
 Class 1
o Asymptomatic
o Rest between activities
 Maternal and Child Nursing
 Class 2 RUBELLA
o Asymptomatic at rest - Congenital rubella syndrome
o Exertion produces symptom o Congenital cataract
o Rest between activities o Glaucoma
o 1 day complete bed rest per week o Microcephaly
 Allows the heart on day to recover o Mental retardation
o Last trimester- CBR o PDA
 Class 3 o Deafness – damage to 8th cranial nerve
o Less than ordinary activities produce symptom o IUGR
o Diet: minimal carb and protein intake, low fat, - Vaccine not given in pregnancy
low sodium - Greater than 1:8 – has antibodies to rubella; has immunity
 Class 4 - Give gamma globulin; not the vaccine
o Symptomatic even at rest
o X for pregnancy CYTOMEGALOVIRUS
o Candidates for ligation  Infection of the genital tract without symptoms
o Managed like 3rd classification  Infects baby’s brain and damage developing bone
o Delivery: forceps assisted structures
 Decompensation – Tachycardia – cardiac arrest  Fetal effects:
 Compensation - Bradycardia o Microcephaly
o Cerebral calcification
Effects of cardiac disease on pregnancy o Chorioretinitis
 LBW baby due to decrease placental perfusion o Hepatosplenomegaly – possible bleeding
 If taking anticoagulant could be teratogenic internally
 May cause premature labor and delivery  Neonatal period
o Early jauncie
Management o Hematemesis
 Digitalis o Melena
 Propanolol o Hematuria
 Spironolactone o Death
o Need potassium for heart contractility  Management
 Penicillin o Antiviral (Zovirax)
o Prophylaxis for upper respiratory tract infection  Not safe in early part of pregnancy
caused by GABHS sequela is rheumatic heart (teratogenic)
disease  Prevention
 Delivery: CS or NSD(epidural anesthesia) o Avoid having sex with a possible contaminated
o Best: forceps!! Like PIH partner
 Most critical time: 1st 24 hours o Have a monogamous relationship
o w/o for tachycardia

TORCH INFECTIONS HERPES

TOXOPLASMOSIS  Painful vesicles in the vulva and peri-anal area
 Caused by parasite/protozoa  Zoster - chickenplox
 Can be ingested - Infected meat of animals (not well  Simplex
cooked) o Herpes Simplex 1 - Oral
 From droppings of animals - Droppings of cat feces o Herpes Simplex 2 - Genital-dangerous for baby
 From unpasteurized milk (anal and genital)
 Fetal effects:  Resembles same lesion as syphilis (chancre-painless-
o Fetal hydrocephaly syphilis)
o Chorioretinitis  Cauliflower like lesion that is PAINFUL
o Cebrebral calcification  Has periods of remission and exacerbation
o May cause repeated abortion  Complications – shedding the virus: direct transmission of
 Management virus to baby
o Cook food very well  Management: CS delivery
o Antibiotics – Sulfa drug (terratogenic effects
noted after treatment is given) LABOR AND DELIVERY
o Abortion is an option
 Complication Labor - series of events whereby the products are expelled
o Can infect brain of mom and baby Powers of Labor
 Prevention - Primary power - uterine contrations (involuntary)
o Eat only well cooked meat, do not touch cat o Protaglandin cascade
litter o Oxytocin
o Progesterone deprivation
OTHERS o Uterine stretched theory
 Chickenpox - Secondary power – intra-abdominal pressure
 Hepatitis B o Needed in 2nd and 3rd stage of labor
o Transferred through placenta or breastfeeding
o Mommy can breastfeed because there are Early postpartum – 24 hours postpartum
immunoglobulins that can be given to baby Late postpartum – 6 months
before feeding

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 Maternal and Child Nursing
Factors that Affect Labor  Brow (sinciput) - moderately flexed
Passage head
 Pelvis (more important)  Face - exaggerated extension of the
o Assessed through pelvimetry head
o Hip bones (innominate bones)  Mentum – chin presentation
 Ilium, ischium and pubis, coccyx, o Breech
sacrum  Complete
o False Pelvis- where the uterus is  Flexed at thighs and flexed at
o Linea terminalis- separates false pelvis from true knees
pelvis  Squatting position
o True Pelvis  Buttocks and legs are
o Diagonal Conjugate presented
 DIstrance of anterior margin of the  Difficult to deliver because it
pubic to the sacrum (pelvic inlet) has 2 presenting parts
 Widest anteroposterior diameter (compound presentation) -
 11.5-12.5cm CS delivery
o True Conjugate (Vera)  Frank
 From lower margin of pubis to sacrum  Flexed at the thighs and
 Less than 1.5 or 2 cm from the diagonal extended at the knees
conjugate  Head cannot flex on its way
o Ischial Diameter (bi-ischial/inter-tuberous) out  Mariceu’s Maneuver –
 Outlet (transverse diameter) attempt to flex the head in a
 Always greater than 8 cm breech delivery
o Gynecoid  Use of Piper’s forceps –
 Round-shaped; most ideal forceps on the chin to flex
 Wide antero-posterior diameter  Incomplete/Footling
o Anthropoid  Legs are extended
 Wide inlet, narrow outlet  Single or Double footling
 Allows vaginal delivery through forceps o Shoulder
o Platypelloid  Baby is on a transverse lie
 Oval
 Wide transverse, narrow AP diameter o Persistent Occiput Posterior/ Back Labor
 Wide inlet, narrow outlet  Arrested after 45 degrees
 CS delivery  Position: side-lying
o Android  Back rub/ sacral massage
 Pelvis that is narrow on all sides  Delivery position: side lying
 We are all android before  Fetal Station – degree of descent on the ischial spine,
 Bone of women thins  widens relationship of the presenting part to the level of the ischial
 Height less than 4”10 spine
o Linea Terminalis o (-) – floating
 Imaginary line that separates the false o 0 – at the level of ischial spines
from the true pelvis o (+) – engaged
o Cephalopelvic Disproportion o +3 – crowning
 Baby’s head size is not in proportion to  Seen at the vulva
the maternal pelvic size o Primi – 1 hour per station
 Soft tissues o Multigravida – 30 mins per station

Passenger The relationship between the passage and fetus

 Size of the fetal head – presenting part  Ischial Spine
o AP diameter  Stations
o Occipitomentum- 13.5
o Occipitofrontal- 12 Powers (Physiologic forces)
o Suboccipitobragmatic- 9.5  Primary: Uterine Contraction - involuntary; contracts due
o Biparietal- 9 to
o Bi-temporal- 8 o Hormone release
o Bimastoid- 7 o Uterine Stretch theory
 Secondary: Intra-abdominal Pressure – voluntary
 Fetal attitude/habitus - degree of flexion of a part o Small amount of pushing
 Fetal position – relation of the point of reference o Done on second and third stage
(denominator) to the quadrants of the pelvic inlet, where
the occiput (cephalic), buttocks (breech), or shoulder Duration – start to end of contraction A-C
blade(acromio) is facing Interval – space between two contraction C-D
 Fetal lie – relationship of fetal long axis and long axis of Frequency – start to start of each contraction A-D
mother Intensity – hardness of the abdomen
 Fetal presentation – part seen first the fetus that is lying in o Assessed using tocodynamometer
the inlet or at the cervical os Frequency and duration increases are labor progresses
o Cephalic Interval becomes shorter as labor progresses
 Vertex (occiput) - well flexed head

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 Maternal and Child Nursing
Psychosocial Considerations Phases of First Stage
 Fear + Anxiety = Pain Latent Active Transition
o Reduce fear and anxiety 0-3 cm 4-7 8-10
o Gate Control Theory Intervals: 5-30 3-5 minutes 2-3 minutes
 Substantiagelatinosa minutes
 Open gate- pain Duration: 30 sec 45-60 60-80
 Close- no pain Calm, walking Irritable, Behavioral change,
o To close the gate: diversion/distract the mother Narcissistic may lose control
 Birth Center - relatives can be with the mother
 LDR Room - labor delivery recovery  Latent Phase
 Water Birth - Baby is a good swimmer  adjustment is o Time when woman is most comfortable; not in
faster pain
o Multipara- go to the hospital agad
o Primipara had lightening, after 2 weeks goes into
Position labor
- Described the relation of the point of reference o Multipara had lightening, labor the same day
(denominator) to the quadrants of the pelvic inlet o Nsg Dx: Anxiety and knowledge deficit; update
her of the status
3 Reasons for Lithotomy Position o Interventions:
- Use forceps  Upright position to make the baby
- Physician intends suture descend faster, deep breathing
- Baby is in breech position exercise, clear liquid diet, BP q1, FHT
q30
Signs of True Labor vs. False 
1. Location – abdomen radiating to the back  Active Phase
2. Positional changes – intensifies the pain (if relieved by o When the patient can’t handle the pain, give
walking, false) pain meds
3. Rhythm – regular  Demerol (meperidine hydrochloride)
4. Cervix – dilated  Antidote: naloxone
o Phenergan- reduce secretion
STAGES OF LABOR AND DELIVERY  Potentiates the effect of Demerol
Stage 1: Cervical Dilation and Effacement  Get RR and FHR
 Begins with true labor and ends with cervical dilatation o Nsg Dx: Acute pain
and effacement o Interventions:
 Effacement first before dilation  Breathing: Pursed-lip
o Fully effaced- both internal and external os meet breathing/accelerated breathing
 Multipara- almost the same time for dilation and  Massage (effleurage) - light stroking of
effacement the abdomen
 Duration: 12-18 hours for primi; 6-8 hours for multi  Pain relief (Demerol, Nubain) – given at
 Prolonged Labor 5 to 6 cm
o Greater than 18 hours in a primi  Antidote: Narcan/Naloxone
o Greater than 12 hours in a multi  Change position
 Precipitate labor  Acupressure
o faster than 3 hours  Hoku acupressure point-
o danger of laceration and head injury improve contraction but not
o May be given tocolytic (Bricanyl) can be given increase the pain
for women who are: grand multi, premature  NPO with IVF
babies in good position, overuse of oxytocin,  Left side lying
large pelvis  Activity: None
 BR on her side
HYPOTONIC HYPERTONIC  FHT q 15, BP q30
Decreased intensity when Strong intensity at the start of
woman has entered Active labor (latent phase) o Fetal Monitoring
phase There 2 sources of contraction  Early deceleration (before acme)
Cervix will not dilate  head compression,
Cause fetal distress  no variability
At risk = multi At risk = primi  continue monitoring
Tx: oxytocin Tx: Morphine  Late deceleration
For every hour oxytocin, Causes respiratory distress  Uteroplacental insufficiency
there should be 1 cm -labor can progress  Fetal distress
cervical dilation  Nsg care:
Why not tocolytic?? Uterus o Turn off pitocin
If not responding  CS might not contract o Side-lying
o Start oxygen
 Pacemaker- start of contraction o Call the
o Fundus doctor(anticipate
CS)
 Oxytocin stress test

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 Maternal and Child Nursing
o As if woman is in o Identification – identifies features that are the
labor baby’s
o 3x in 20 mins o Attachment
o 45-60 seconds  Rooming - in to promote bonding
o Reactive – NO LATE  For stillbirth and baby’s with defect
DECELERATION o Relay news immediately
 Variable deceleration o Tell mother the positive first then the negative
 Unstable flow of blood to o Break it to me gently
baby
 Cord compression due to  Cord Coil or Nuchal Cord
prolapse o Wait until pulsations stop
 Beat to beat variability o First clamp 2cm from base (plastic)
 Nsg care: o Second clamp 3cm away from the first (forcep)
o Stop pitocin o Third clamp 5cm away from the first (forcep)
o Oxygen before CS o Cut as close to the edge of the plastic clamp as
 Transition Phase possible
o Ready to give birth o Multiple coil – clamp and cut
o Primi = 1 hour; multi 10-15 mins o Single coil - loosen
o Fear of losing control
o Accompanying symptoms of n/v, trembling of Stage 3: Placental Delivery
legs, pressure on bladder and rectum, - 5-30 mins
circumoral pallor - Placental time (duration) - starts when fetus is expelled
o Nsg Dx: Fear of losing control and ends with placental expulsion
o Breathing: Panting and Blowing
o Stirrups Signs of Separation
 Put legs on the stirrup at the same time 1. Uterus fundus rises in the abdomen and forms a globular-
to prevent over stretching of ligament, shaped uterus (Calkin’s sign) – 1st sign
changing pressure inside the uterus 2. Sudden trickle or gush of blood
 Adjust height of stirrup when she sits up 3. Umbilical cord lengthens
for bearing down  After delivery, check the uterus if it is contract
o 6 strokes in perineal prep – pubis, leg, leg, labia  To stimulate contraction
,labia, center o Massage the uterus
 Use betadine, assess allergy to protein o Direct stimulation of the pacemaker
o Intervention: help regain control, prepare o After, ice
delivery o Then ergot prep (methergine)
 Acts like an oxytocin
Stage 2 Fetal Stages  Works in 15 minutes
 Starts when cervix is fully dilated and effaced ends on  Increase in BP
expulsion  Brandt Andrew’s technique - remove placenta
 6 Cardinal Movements/ 7 Mechanisms of Fetal Movement  Crede’s Maneuver – remove placenta with fundal
o *Engagement push
o Descent
o Flexion Placenta accreta
o Internal Rotation - Deep attachment of the placenta to the uterine
o Extension myometrium
o External Rotation - Hysterectomy or treatment with methotrexate to destroy
o *Restitution the still-attached tissue may be necessary
o Expulsion o Placenta increta – deep in the myometrium;
 Best position: Where mother is comfortable muscles of uterus
 Sterile drapes - 4 sterile drapes o Placenta percreta – in the perimetrium; beyond
 Instruments the muscle
o Needle holder
o Kelly straight clamp (2) Battledore Placenta
o Mayo Scissor (Not part of the basic set since it is - cord is marginally not centrally; no problem with
a sharp) oxygenation; fragile
o Needles
 Cutting- pass through areas of great Forceps Delivery
resistance - Two double crossed spoon like articulated blades are
 Round used to assist in the delivery of the fetal head
o *Tissue forceps (not part of the basic set) - Check neonate and mother after delivery for any possible
o Thumb forceps injury
o Sterile basin – receptacle for placenta - May have facial nerve damage, Bell’s Palsy
 Crowning- support lower part of the head (Ritgen’s
Maneuver) Vacuum Suction
 Put your finger between the neck to check of there is cord - A cap-like suction device is applied to the fetal heat to
coiling facilitate obstruction
 Deliver the body of the baby - Assess for cerebral trauma and developing
 Bonding cephalhematoma
o Claiming – identified features that are her’s

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 Maternal and Child Nursing
Stage 4: Postpartum  Uterus
 Critical 24 hours is called IMMEDIATE POSTPARTUM o Firm and contracted
o Patient might bleed o Fundus
 Lasts for about 6 weeks but may vary involution  After birth, midway between the
 Puerperium umbilicus and pubis
 Assessment in first 24 hours  Fundus goes down by 1-2cm
o VS q15 minutes for the 1st hour (fingerbreadths) a day
 Q30 for the 2nd and 3rd hour  About 1oth day, uterus is not palpable
 Q1 until 24 hours have passed or until anymore
stable  Bladder
o Change in BP- potential for bleeding (low) o First 24 hours urine = 2500-3000ml
o Check fundus ever 15 mins – check for atony; o May have dehydration; inc temp
massage intermittently
o Check the condition of the uterus every 15  Bowel
 Atony is the common cause of o Give full meal even with IV
bleeding the first 24 hours o IV is only for dehydration
 Lacerations- if not atony o 2 days after delivery, resume of BM
 Laceration of uterine artery  if not able to defecate (constipation)
 Bleeding is bright red laxative or suppository
 Comes out in spurts (with  Lochia
pressure)
 Do immediate repair Type Color Duration Components
Rubra Red, fleshy 1-3 days Blood, fragments of
 Laceration in Vagina with clots deciduas, mucus
 Bright red bleeding Seros Pink/brown, 7 days Blood, mucus,
 Slow trickle a odorless invading leukocytes
 Use pressure dressing Alba White,odorle 1-3 wks Largely mucus,
cherries insert catheter ss leukocyte count high
 Cherries only for 24 hours-
prevent toxic shock syndrome  Episiotomy
o R – redness
 Laceration in Perineum o E- edema
 1st degree- skin o E – ecchymosis
 2nd- all the way to the o D – discharge
perennial area (muscle) o A – approximation
 3rd- anal area affected o Needs order form MD, perineal prep, must be 12
(external) inches away
 4th- rectum included 8Major sign of sepsis – low grade fever/chills
 Late: retained placental
tissue; puerperal sepsis  Homan’s Sign
o Assess blood loss  Emotions
 1000ml = normal for cesarean
 200-400ml = normal for NSD
 More than 500 = hemorrhage Reva Rubin’s Assessment
 Causes in early postpartum: atony,
laceration Taking in Taking hold Letting go
o Check bladder for distention – a distended Mother’s Interests, shifts to infant Bursting out
bladder pushes the uterus out of place which needs and infant’s needs Socializing
may prevent contraction predominate Post partum blues (they Back to work
 Uterus must be like at the level of 5 I cannot do it, want babies, but they
months pregnancy which is midway you do it are afraid); less than 1
between umbilicus and symphisis week
Post partum depression
– psychosis; more than 1
BUBBLE-HE/8-Point Assessment Tool week
 Breast
Dependent Independent Interdependent
o 3rd day woman will start to release milk
1-2 days
(colostrum)
o Engorgement in 2-3 days in multipari; primi in 5
days
o First time – 7 mins max (primi)/ 12 mins max (multi)
o Marmet’s technique - gently pull the nipple twice Maternal and Child Care
if inverted nipple
o Football hold - benefits CS  no pressure in - Millennium development deceleration in 2000
abdomen - Goals: reduce disease and poverty by 2015
o Uterus decends 1-2cm fingerbreaths per day Administrative Order 2008-0029 (DOH)
(involution) - AO 2008-2009 – Implementing Health Reforms towards
 In 10 days, uterus is not palpable Rapid Reduction in Maternal and Neonatal Mortality

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 Maternal and Child Nursing
- AO 2009-0025 – Adopting new policies and protocol on
essential newborn care Criteria for Lying in/ Home Delivery
- AO 2010-0001 – Policies and Guidelines for the Philippine - 18-35 years old
National Blood Services (PNBS) and the Blood Services - Full term, cephalic, NO CPD
Networks (BSN) - Growth appropriate for age
- AO 2010-0010 – Revised Policy on Micronutrient - Gravida 2-4
Supplementation to Support Achievement of 2015 MDG - No medical disorders for complications
Targets to Reduce Under-Five and Maternal Deaths and - Newborn Emergency Functions
Address Micronutrient Needs of Other Population Groups
- AO 2010-0014 – Administration of the saving drugs and
medicine by midwives to rapidly reduce maternal and Partograph
neonatal morbidity and mortality Important Instructions
- Birth registration
3 Levels of MNCHN Sense Delivery Network (SDN) - Importance of BF
- NB screening test
1. Community Level Providers - Cord care
- Outpatient clinics of RHU, BHS, private clinics with - Post-partum visits
health staff and volunteer health workers  1st visit – 1st week postpartum
- Tasks  2nd visit – 6 weeks postpartum
1. Navigation – health risks, access to 1. Newborn Resuscitation
critical health services and financing 2. Treatment of neonatal sepsis
resources 3. Oxygen support
2. Basic Service Delivery Functions – birth 4. Low birth weights of protein
spacing, family planning, counseling, 5. Other specialized newborn services
and other health issues - Can be private or public secondary or tertiary hospital
capable of performing CS and emergency NB care
2. BEmONC Capable Network of Facilities and Providers - Can serve high volume providers for IUD and VSC services
(Basic Emergency Obstetric and Newborn Care) (BTL and no scalpel vasectomy)
- Services - Ideally is less than 2 hours from the residence of priority
1. Parenteral antibiotics population or referring facility
2. Parenteral oxytocic drug
3. Parenteral anticonvulsant Breastfeeding Campaign
4. Removal or retained products - Breastfeeding: The 1st Step to Raising a Child
5. Manual removal of the placenta Unique Characteristics of Breastmilk
6. Assisted vaginal delivery – vacuum or - B – best for baby
forceps - R – reduced allergic reaction
- If the BEmONC is hospital based-blood - E – economical
transfusion services may or may not include - A – always available
collection and screening - S – safe
- Operates on 24 hours basis with skilled health - T – temperature always right
professional - F – fresh always
- 1:125,000 - E – emotional bonding
- E – easily established
3. CEmONC Capable Facility or Network Facilities – end - D – digestible
referral facilities - I – immunity
- Complicated deliveries and newborn - N – nutritious
emergencies - G – GIT disorder decreased
- OB function
1. 6 Basic Functions Under BEmONC Promoting Breastfeeding
2. Blood Banking and Transfusion - Laws
3. Cesarean Delivery o RA 7600 – Rooming-In and Breastfeeding Act of
1992
All Pregnancies to be at risk o E.O. 51 – milk code
- OLD Approach – screening - Health Education
- NEW Approach – should all deliver with o Advantages for breastfeeding
assistance from skilled health professionals Reflexes Involved in Breastfeeding
- Best intra-partum strategy – deliver in health - Prolactin reflex
center with midwives as the main providers but - Letdown reflex
not with others
Technique of Breastfeeding
Maternal Health Programs: Essential Health Packages Positions for Breastfeeding
A. Ante-natal Registration - Cradle hold (Madonna)
B. Tetanus Toxoid Immunization - Football hold
C. Micronutrient Supplementation - Side-lying
D. Treatment of diseases and other conditions
E. Clean and safe delivery
F. Support for breastfeeding
G. Family planning counseling

University of Santo Tomas – College of Nursing / JSV