Академический Документы
Профессиональный Документы
Культура Документы
Maternal and Child Health Nursing involves care of the woman and family
throughout pregnancy and child birth and the health promotion and illness care
for the children and families.
Estrogen: promotes breast dev't & pubic hair distribution prevents osteoporosis
keeps cholesterol levels reduced & so limits effects of atherosclerosis Fallopian tubes.
1 Approximately 10 cm in length
2 Conveys ova from ovaries to the uterus
3 Site of fertilization
4 Parts: interstitial
isthmus - cut/sealed in BTL
ampulla - site of fertilization
infundibulum - most distal segment; covered with fimbria
2. Uterus
1 Hollow muscular pear shaped organ
• uterine wall layers: endometrium; myometrium; perimetrium
2 Organ of menstruation
3 Receives the ova
4 Provide place for implantation & nourishment during fetal growth
5 Protects growing fetus
6 Expels fetus at maturity
7 Has 3 divisions: corpus - fundus , isthmus (most commonly cut during CS
delivery) and
cervix
3. Uterine Wall
1 Endometrial layer: formed by 2 layers of cells which are as follows:
2 basal layer- closest to the uterine wall
3 glandular layer - inner layer influenced by estrogen and progesterone; thickens and
shed off
as menstrual flow
4 Myometrium - composed of 3 interwoven layers of smooth muscle; fibers are
arranged in longitudinal; transverse and oblique directions giving it extreme strength
4. Vagina
5 Acts as organ of copulation
6 Conveys sperm to the cervix
7 Expands to serve as birth canal
8 Wall contains many folds or rugae making it very elastic
Fornices - uterine end of the vagina; serve as a place for pooling of semen following
coitus
Bulbocavernosus - circular muscle act as a voluntary sphincter at the external opening
to the
vagina (target of Kegel's exercise)
3
the stage of life at which secondary sex changes begins
the development and maturation of reproductive organs
which occurs in female 10-13 years old & male at 12-14 yrs old
the hypothalamus serve as a gonadostat or regulation
mechanism set to "turn on" gonad functioning at this age
2. Reproductive Development
Role of Androgen
1 Androgenic hormones - are produced by the testes, ovaries and adrenal cortex which
is responsible for:
muscular development
physical growth
inc. sebaceous gland secretions
1 testosterone -primary androgenic hormone
Related terms
a. Adrenarche - the development of pubic and axillary hair (due to androgen
stimulation)
b. Thelarche - beginning of breast development
c. Menarche - first menstruation period in girls (early 9 y.o. or late 17 y.o.)
d. Tanner Staging
2 It is a rating system for pubertal development
3 It is the biologic marker of maturity
4 It is based on the orderly progressive development of:
5 breasts and pubic hair in females
6 genitalia and pubic hair in males
1 Hypothalamus
2 Anterior Pituitary Gland
3 Ovary
4 Uterus
4. Menstrual Cycle
1 Female reproductive cycle wherein periodic uterine bleeding occurs in response to
cyclic hormonal changes
2 Allows for conception and implantation of a new life
3 Its purpose it to bring an ovum to maturity; renew a uterine bed that will be
responsive to the growth of a fertilized ovum
5. Menstrual Phases
• First: 4-5 days after the menstrual flow; the endometrium is very thin, but begins to
proliferate rapidly; thickness increase by 8 folds under the influence of increase in estrogen
level
also known as: proliferative; estrogenic; follicular and postmentrual phase
• Secondary: after ovulation the corpus luteum produces progesterone which causes the
endometrium become twisted in appearance and dilated; capillaries increase in amount
(becomes rich, velvety and spongy in appearance also known as: secretory;
progestational; luteal and premenstrual
• Final phase: end of the menstrual cycle; the first day mark the beginning of a new cycle;
discharges contains blood from ruptured capillaries, mucin from glands, fragments of
endometrial tissue and atrophied ovum.
Physiology of Menstruation
1. About day 14 an upsurge of LH occurs and the graafian follicle ruptures and the ovum
is released
2. After release of ovum and fluid filled follicle cells remain as an empty pit; FSH
decrease in Amount; LH increase continues to act on follicle cells in ovary to produce
lutein which is high in progesterone ( yellow fluid) thus the name corpus luteum or
yellow body
3. Corpus luteum persists for 16 - 20 weeks with pregnancy but with no fertilization
ovum atropies in 4 - 5 days, corpus luteum remains for 8 -10 days regresses and
replaced by white fibrous tissue, corpus albicans
Associated Terms
Ovulation
1 Occurs approximately the 14th day before the onset of next cycle (2 weeks before)
2 If cycle is 20 days - 14 days before the next cycle is the 6th day, so ovulation is day 6
3 If cycle is 44 days - 14 days, ovulation is day 30.
4 Slight drop in BT (0.5 - 1.0 °F) just before day of ovulation due to low progesterone
level then rises 1°F on the day following ovulation (spinnbarkheit; mittelschmerz)
5 If fertilization occurs, ovum proceeds down the fallopian tube and implants on the
endometrium
Menopause
o Mechanism- a transitional phase (period of 1 - 2 years) called climacteric, heralds
the onset of menopause.
o Monthly menstrual period is less frequent, irregular and with diminished amount.
o Period may be ovulatory or unovulatory - advised to use Family planning method until
menses have
been absent for 6 continuous months
o Menopause is has occurred if there had been no period for one year.
A. Artificial Methods:
1. physiologic method: oral contraceptives ; natural methods
2. mechanical methods
3. chemical methods
4. surgical methods
Oral contraceptive
Action:
Types:
inhibits release of FSH _ no ovulation
Combined ; Sequential; Mini pill
Side Effects: due to estrogen and progesterone
> nausea and vomiting
> breast tenderness
> breakthrough bleeding/spotting
> chloasma
Contraindications:
a. Breastfeeding
b. Certain diseases:
o thromboembolism
o Diabetes Mellitus
o Liver disease
> Headache and weight gain
> dizziness
o migraine; epilepsy; varicosities
o CA; renal disease;recent hepatitis
c. Women who smoke more than 2 packs of cigarette per day
d. Strong family Hx of heart attack
Note: If taking pill is missed on schedule, take one as soon as remembered and
take next pill on schedule; if not done withdrawal bleeding occurs.
B. Natural Methods:
C. Mechanical Methods
1.
Intrauterine Device - prevents implantation by non-specific cell
inflammatory reaction
inserted during menstruation (cervix is dilated)
SE:
increased menstrual flow
spotting or uterine cramps
increased risk of infection
Note: when pregnancy occurs, no need to remove IUD, will not harm
fetus
2.
o
o
o
o
o
3.
Diaphragm
a disc that fits over the cervix
forms a barrier against the entrance of sperms
initially inserted by the doctor
maybe washed with soap and water is reusable
when used, must be kept in place because sperms remains viable for 6 hrs.
in the vagina but must be removed within 24 hours (to decrease risk of
toxic shock syndrome)
Condom
1 a rubber sheath where sperms are deposited
2 it lessens the chance of contracting STDs
3 most common complaint of users _
interrupts sexual act when to apply
D. Chemical Methods
These are spermicidals (kills sperms) like jellies, creams, foaming tablets,
suppositories
E. Surgical Method
a.
b.
couple
Tubal Ligation:
Fallopian tubes are ligated to prevent passage of sperms
Menstruation and ovulation continue
Vasectomy:
Vas deferens is tied and cut blocking the passage of sperms
Sperm production continues
Sperms in the cut vas deferens remains viable for about 6 months hence
A. Fertilization
1. Union of the ovum and spermatozoon
2. Other terms: conception, impregnation or fecundation
3. Normal amount of semen/ejaculation= 3-5 cc = 1 tsp.
4. Number of sperms: 120-150 million/cc/ejaculation
5. Mature ovum may be fertilized for 12 -24 hrs after ovulation
6. Sperms are capable of fertilizing even for 3 - 4 days after ejaculation (life
span of sperms 72 hrs)
B. Implantation
General Considerations:
o Once implantation has taken place, the uterine endometrium is now termed
decidua
o Occasionally, a small amount of vaginal bleeding occurs with implantation due to
breakage of capillaries
o Immediately after fertilization, the fertilized ovum or zygote stays in the
fallopian tube for 3 days, during which time rapid cell division (mitosis) is
taking place. The developing cells now called blastomere and when about to
have 16 blastomere called morula.
o Morula travels to uterus for another 3 - 4 days
o When there is already a cavity in the morula called blastocyt
o finger like projections called trophoblast form around the blastocyst, which
implant on the uterus
o Implantation is also called nidation, takes place about a week after fertlization
E. Amniotic Fluid
Implication:
Polyhydramios = more than >1500 ml due to inability of the fetus to swallow the fluid
as in
trachoesophageal fistula.
Oligohydramnios = less than <500 ml due to the inability of the kidneys to add urine
as in
congenital renal anomaly
F . Fetal Membranes
•Chorion - together with the deciduas basalis gives rise to the placenta, start to form at
8th
week of gestation; develops 15 - 20 cotyledons
2. Mesoderm - forms into the supporting structures of the body (connective tissues,
cartilage, muscles and tendons); heart, circulatory system, blood cells, reproductive
system, kidneys and ureters.
3. Ectoderm - responsible for the formation of the nervous system, skin, hair and nails
and the
mucous membrane of the anus and mouth
1 month: 2nd week - fetal membranes
beats
16th day - heart forms ; 4th week - heart
2nd month: All vital organs and sex organs formed; placental fully developed;
meconium formed (5th -8th wk)
3rd month: Kidneys function - 12th wk- urine formed ; Buds of milk teeth form ; begin
bone ossification ; allows amniotic fluid ; establishment of feto-placental exchange
4th month: Lanugo appears; buds of permanent teeth form; heart beat heard by fetoscope
5th month: Vernix appears; lanugo over entire body; quickening; FHR audible with
stethoscope
6th month: Attains proportions of full term but has wrinkled skin
8th month: 32 weeks - fetus viable; lanugo disappears, subcutaneous fat deposition begins
9th month: Lanugo continue to disappear; vernix complete; amniotic volume decrease
Focus of Fetal Development
Second Trimester - period of continued fetal growth and development; rapid increase in
length
Third Trimester - period of most rapid growth and development because of the deposition
of
subcutaneous fat
Assessing Fetal Well-being
Fetal Movement:
Quickening at 18 - 20 weeks , peaks at 29 -38 weeks
Consistently felt until term
a. Cardiff Method:
b. Contraction Stress Test:
contractions
"Count to ten" - records time interval it takes for 10
- fetal movements to be felt _ usually occurs
in 60
minutes
c. Non-stress Test:
20mins.) _
Measures response of FHR to fetal movement (10-
b. Palpitations
caused by the SNS stimulation during early part of pregnancy; increased pressure of
the uterus
against the diaphragm during the second half of pregnancy
2. Gastrointestinal Changes
a. Morning sickness
2 nausea and vomiting in the 1st trimester due to HCG or due to increased acidity or
emotional
factors
3 Management: dry toast 30 mins before get up in AM
b. Hyperemesis gravidarum
4 excessive nausea & vomiting which persists beyond 3 months causing dehydration,
starvation and acidosis
5 Management: hydration in 24 hrs; complete bed room
d. Hemorrhoids
1 due pressure of enlarged uterus
2 Management: cold compress with witch hazel and Epsom salts
e. Heartburn
1 due to increased progesterone and decreased gastric motility causing regurgitation
through gastric sphincter
2 Management: pats off butter before meals
avoid fried, fatty foods
sips of milk at intervals
small, frequent meals taken slowly
don't bend on waist
take antacids (milk of magnesia)
3. Respiratory Changes
a. Shortness of Breath
due to inc. oxygen consumption and production of carbon dioxide during the 1st
Trimester;
and increased uterine size pushing the diaphragm crowding chest cavity
management: side lying position to promote lateral chest expansion
4. Urinary Changes
a. Urinary frequency
felt during the 1st trimester due to the increase blood supply to the kidneys
and then on
the 3rd trimester due to pressure on the bladder.
5. Musculoskeletal changes
a. Pride of Pregnancy
1
b. Waddling gait
due to need to change center of gravity result to lordotic position
1 due to increased production of hormone relaxin, pelvic bones becomes more
movable
2 increasing incidence of falls
c. Leg cramps
1
due to pressure of gravid uterus, fatigue, muscle tenseness, low calcium and
phosphorus intake
6. Endocrine Changes
a. Addition of the placenta as an endocrine organ producing HCG, HPL, estrogen
and progesterone
b. Moderate enlargement of the thyroid due to increased basal metabolic rate
c. Increased size of the parathyroid to meet need of fetus for calcium
d. Increased size and activity of adrenal cortex increasing circulating cortisol,
aldosterone, and ADH which affect CHO and fat metabolism causing
hyperglycemia.
e. Gradual increase in insulin production but there is decreased sensitivity to
insulin during pregnancy
7. Weight Change
a. First Trimester 1.5 to 3 lbs normal weight gain
b. 2nd and 3rd trimester 10 - 11 lbs per trimester is recommended
c. Total allowable weight gain during throughout pregnance is 20 - 25 lbs or 10 -
12 kgs.
d. Pattern of weight gain is more important than the amount of weight gained.
8. Emotional responses
a. 1st trimester: some degree of rejection, disbelief, even depression because of
its future implication -> give health teachings on body changes and allow for
expression of feelings
b. 2nd trimester: fetus is perceived as a separate entity and fantasizes
appearance
c. 3rd trimester: best time to talk about layette, and infant feeding method. To
allay fear of death let woman listen to the FHT.
• Stress -decrease in responsibility taking is the reaction to the stress of pregnancy not the
pregnancy itself _ affects decision making abilities
• Change in Sexual Desire - may increase or decrease _ needs correct interpretation… not
as a loss of interest in sexual partner
1. Uterus - wt increase to about 1000 grams at full term due to increase in fibrous and elastic
tissues
a. Becomes ovoid in shape
b. Softening of lower uterine segment: Hegar's sign seen at 6th week
c. Operculum - mucus plug to seal out bacteria
d. Goodell's sign - cervix becomes vascular and edematous giving it consistency
of the earlobe
3. Ovaries
Inactive since ovulation does not take place during pregnancy. Placenta produces
Progesterone and Estrogen during pregnancy
4. Abdominal Wall
1 Striae Gravidarum - due to rupture and atrophy of connective tissue layers on the
growing abdomen
2 Linea Nigra
3 Umbilicus is pushed out
4 Melasma or Chloasma - increased pigmentation due increased production of
melanocytes by the pitutitary
5 Unduly activated sweat glands
1 Prenatal care is important for prevention of infant and maternal morbidity and
mortality
2 Care is a cooperative action based on client's understanding of treatment modalities
3 Duration of normal pregnancy 266 - 280 days of 38 - 42 weeks or 9 calendar months
or 10 lunar months.
4 Infant born < 38 weeks pre-term & 42 post term)
5 Diagnosis: Urine examination - tests presence of HCG (present from 40th -100th day,
peak 60 days) conduct test 6 weeks after LMP
2. Prenatal Visit
History Taking:
personal data
gravida
TPAL
present pregnancy: cc
medical data: hx of diseases/illnesses
5. Important Estimates:
a. Age of Gestation:
•
Nagele's Rule: -3 calendar months and +7 days
engaged)
regardless of interval.
= 3 booster doses is equal to lifetime immunity
b. PASSENGER - Fetus
b.2. Fontanels - membrane covered spaces at the junction of the main suture lines
anterior fontanel: larger, diamond shaped; closes at 12 - 18 months
posterior fontanel: smaller, triangular shaped, closes at 2 - 3 months
b.3. Fetal Lie - relationship of the cephalocaudal axis of the fetus to the cephalocaudal
axis of the
mother.
Measurements:
b.4. Fetal Attitude - fetal position
Pelvis is divided into 6 areas: Anterior, Posterior, Transverse Left,
Transverse
Right, Posterior Left, Posterior Right
Fetal landmarks: Occiput (O); mentum (M), sacrum (S), and scapula (Sc)
b.5. Presentation -the part of the passenger that enters the pelvis is the presenting part
a. Cephalic - Vertex (occiput) ; Brow (sinciput); Face (mentum)
b. Breech - Complete (sacrum) ; Frank; Footling
c. Shoulder
c.1. Divisions
a.
b.
False Pelvis -supports the growing uterus during pregnancy
-directs the fetus into the true pelvis near the end of gestation
True Pelvis: the bony canal through which the fetus will pass during delivery formed
by the pubis in front, the iliac and ischia on the sides and the sacrum and
coccyx behind
c.2. Significant Pelvic Measurements
>Obstetrical Conjugate
- the distance from the inner border of the symphysis pubis to the sacral
prominence
- most important pelvic measurement
- shortest AP diameter of the inlet through which the head must pass
- 1.5 to 2 cm or less than the diagonal conjugate
>True Conjugate/Conjugate Vera
- the distance between the anterior surface of the sacral promontory and superior
margin
of the symphysis pubis
- diameter of the pelvic inlet (10.5 -11 cm)
a. Lightening
b. Increased activity level- "nesting behavior"
c. Loss of weight ( 2-3 lbs)
d. Braxton Hick's Contractions
e. Cervical Changes - effacement
- Goodell's sign - ripening of the cervix
f. Increase in back discomfort
g. Bloody Show - pinkish vaginal discharge
h. Rupture of Membranes- labor expect in 24 hours
i. Sudden burst of energy
j. Diarrhea
k. Regular Contractions - phases: increment,acme,decrement
- characteristics: intensity, frequency, interval,
duration
False Labor Pains
o1 Remain irregular
o2 Confined to abdomen
o3 No increase in duration, frequency,
intensity
o4 Disappears on ambulation
o5 No cervical changes
True Labor Pains
1. Stages of Labor
Stage
First Stage
- the stage of true labor until the
complete cervical dilatation
Characteristics
Extent:
Primigravida - 3.3.-19.7 hrs
Multigravida - 0.1 - 14.3 hrs
a. Latent Phase
b. Active Phase
c. Transitional
Phase
0-4 cms. cervical dilatation
Interval: 15-20 mins interval
Duration: 10-30 seconds
rd
4. Nursing Care of Woman in the 3 Stage of Labor
a. Principle Of Watchful Waiting
b. Use Brandt Andrews Maneuver
c. Note Time Of Delivery (20 Minutes After Delivery Of The Baby)
d. Check Bp; Injects Oxytocin (Methergin 0.2 Mg/Ml Or Syntocinon 10 U/Ml Im)
e. Inspect Cotyledons For Completeness
f. Check Uterus For Contraction
g. Check Perineum For Lacerations -Give perineal care; apply perineal pads
h.
i.
j.
k.
l.
Change gown
Place flat on bed
Keep warm - provide extra warm blanket
Give initial nourishment - warm milk, tea
Allow to rest/ sleep
5. Nursing Care of Woman in Fourth Stage
a. Lactation: promote lactation by encouraging early breastfeeding to stimulate
milk
production
*** Those mothers who cannot breastfeed:
suppressing agents are given - estrogen- androgen preparations given
first hours
post partum to prevent milk production. These drugs tend to increase
uterine
bleeding and retard involution. (e.g. diethylstilbestrol, Parlodel or
deladumone)
b. Rooming-in-concept
provides opportunity for developing positive family relationship
promotes maternal infant bonding
releases maternal caretaking responses
8. Categories of Lacerations
8.1. First degree - involves vaginal mucous membrane and perineal skin
8.2. Second degree - involves the perineal muscles, vaginal mucous membrane
and
perineal skin
8.3. Third degree - involves all in the 2nd degree lacerations and the external
sphincter of
the rectum
8.4. Fourth degree - involves all in 3rd degree lacerations and the mucus
membrane of the
rectum
1. Vascular Changes
- Reabsorption of the 30-50% increase in cardiac volume within 5 - 10 minutes after
the third
stage of labor.
- WBC increases to 20,000 - 30,000/mm³
- Activation of the clotting factor
- All blood values are back to prenatal levels by 3rd or 4th week
Nursing Care:
•
•
•
Explain to client cause of pain
Do not apply heat
Administer analgesics as prescribed
3. Genital Changes/ Discharges
- Presence of Lochia: uterine discharges consisting of blood, decidua, WBC and some
bacteria
- Characteristics:
pattern should not reverse -
1-3 days - rubra - - - bright red with no or minimal clots
4-9 days - serosa- - - thinner, serous sanguinous blood
10- 3 to 6 wks pp - alba - - - whitish discharge
same amount as menstrual flow, decreased if with breastfeeding , increased
with activity
with fleshy odor; never foul smelling
4. Perineal Pain
Nursing Care:
• Place in Sim's position - lessens strain on the suture line
•
•
•
5. Sexual Activity
Expose to dry heat or warm Sitz bath
Application of topical analgesics or oral analgesics as ordered
Provide/ encourage perineal care
1 sexual stimulation may be decreased due to emotional factors and hormonal
changes
2 it may be resumed if bleeding has stopped and episiorrhaphy has healed by
the 3rd or
4th week
6. Menstruation
1 Breastfeeding influences return of the menstrual flow.
2 Breastfeeding - menses return in 3 - 4 months;
o some do not menstruate throughout lactation period
o ovulation is also possible with lactational amenorrhea
3 Non-Breastfeeding Mothers - menstrual flow return within 8 weeks
7. Urinary Changes
o marked diuresis occurs within 12 hours postpartum to eliminate excess tissue
fluids during pregnancy
o frequent urination in small amounts may be experienced by some
o others have difficulty of urination
Nursing Care:
•
•
Explain cause of urinary changes
Assist to promote voiding utilizing appropriate measures (encouraging
voiding, let client listen to sound of flowing water, etc.)
8. Gastrointestinal Changes
- Change is more on the delay of bowel evacuation; constipation
- Cause:
decreased muscle tone
lack of food intake
dehydration
fear of pain
-Nursing Care: encourage early ambulation
increase fluids
increase fibers in the diet
9. Vital Signs
o Temperature: may increase because of dehydration on the first 24 hours pp.
o CR 50 - 70 beats/min (bradycardia) is common for 6 - 8 days pp.
o RR - no change is expected
o Weight = 10 - 12 lbs is expected to be immediately lost. This corresponds to the
weight of the fetus, placenta, amniotic fluid and blood. Diaphoresis will
contribute to further weight loss
Postpartum Blues - overwhelming sadness that cannot be accounted for. Could be due
to
hormonal changes, fatigue or feelings of inadequacy.
Implications of lactation:
1 Breast milk will be produced postpartum
2 Lactation do not occur during pregnancy due to levels of estrogen and progesterone
3 Lactation suppressing agents are to be given immediately after placental delivery to be
effective
4 Oral contraceptives decrease milk supply and are contraindicated in lactating mothers
5 Afterpains are felt more by breastfeeding mothers due to oxytocin production; have
less lochia and rapid involution
b. Feeding Techniques
1. Engorgement
• breast becomes full, tense and hot with throbbing pain
• expected to occur on the 3rd post partum day accompanied by fever (milk fever)last
for 24 due to increased lymphatic and venous circulation
Nursing care:
o encourage breastfeeding
o advise use of firm-supportive brassiere
o (if not going to breastfeed - apply cold compress; no massage; no breast
pump; apply
breast binder)
0
2. Sore Nipples
Nursing care:
encourage to continue BF
expose nipples to air for 10 - 15 minutes after feeding
(alternative) exposure to 20 watt bulb placed 12 - 18 inches away promotes
vasodilation
and therefore promote healing
do not use plastic liners
use nipple shield
Signs & Symptoms: pain, swelling, redness, lumps in the breasts, milk becomes
scanty
Nursing Care:
Ice compress
Supportive brassiere , empty breast with pump
Discontinue BF in affected breast
Apply warm dressing to increase drainage
Administer antibiotics as prescribed
1. Infections
2. Bleeding / Hemorrhage/ PIH
3. Diabetes Mellitus
4. Heart Disease
5. Multiple Pregnancy
6. Blood Incompability
7. Dystocia
8. Induced Labor
9. Instrumental Deliveries
1. INFECTIONS
1.1. Syphilis
Cause:
intercourse
Treatment:
x 10 days
Untreated:
Treponema pallidum - a spirochete transmitted thru sexual
H erpes type 2
(CMV) (DNA virus)
Group of maternal systemic infections that can cross the placenta or by ascending
infection
(after rupture of membranes) to the fetus.
Infection early in pregnancy may produce fetal deformities, whereas late infections
may result in
active systemic disease and/or CNS involvement causing severe neurological
impairment or
death of newborn
Sources/ Cause:
1. Endogenous/primary sources - normal bacterial flora
2. Exogenous sources - hospital personnel, excessive obstetric manipulations
breaks in aseptic techniques, coitus late in pregnancy
premature rupture of membranes
Management:
Complete Bedrest
Proper Nutrition
Increased Fluid Intake
Analgesics
Antipyretics and antibiotics as ordered
Management: drain area & resuturing ; sitz bath & warm compress
1.4. Endometritis
- An infection/inflammation of the lining of the uterus
1.5. Thrombophlebitis
Foul smelling lochia
-infection of the lining of a blood vessel with formation of clots, usual an
extension of
endometritis
Specific Management:
1
2
bed rest with affected leg elevated
anticoagulants (e.g. Dicumarol or Heparin) to prevent
formation or extension of a thrombus
Side effect of Anticoagulant: hematuria, increased lochia
Considerations:
1 discontinue breastfeeding
2 monitor prothrombin time
3 have Protamine Sulfate at bedside to counter act severe bleeding
4 analgesics are given but not ASPIRIN because it prevents
prothrombin formation
which may lead to hemorrhage
2. HEMMORRHAGE/ BLEEDING
Definition: blood loss more than 500 cc. ( normal blood loss 250- 350 cc)
*** Leading cause of maternal mortality associated with childbearing
2.1. Early Post-partum hemorrhage - first 24 hrs after delivery
Predisposing factor:
Early Post-partum hemorrhage
Lacerations
Hypofibrinogenemia
Clotting defect
blood transfusion
Late Postpartum Hemorrhage
Predisposing Factors:
a. large fetus
b. Older than 35, younger than 17
c. primigravida
d. multiple pregnancy or H mole
e. poor nutrition
f. Hx of DM, renal and vascular disease
g. Morbid obesity or weight less than 100 lb
h. Family history
Diagnosis:
Roll - over test : Assess the probability of developing toxemia when done
between the
28th and 32nd week of pregnancy.
b. Pre-eclampsia, mild
o BP of 140/90 mmHg or increase of 30/15mmHg
o 2+ to 3+ proteinuria
o begins past 20th week
o slight generalized edema may be present, weight gain of 1- 5
lbs/wk
c. Pre-eclampsia, severe
o BP of 150-160/100-110 mmHg
o 4+ proteinuria (5 gm/L or more in 24 hrs
o Headache and epigastric pain(aura to convulsions)
o Oliguria of 400 ml or less in 24 hrs. (normal UO/day 1500 ml)
o Cerebral or visual disturbances
f. Cathartic - cause shift of fluid from the extra cellular spaces into the
intestines from where the fluid can be excreted
Dosage:
10 gms initially -either by slow IV push over 5 - 10 minutes or
deep IM,
5 gms/buttock, then an IV drip of 1 gm per hour (1 gm/100 ml
D10W),
Nursing Intervention:
a.
b.
c.
d.
e.
f.
Advised bedrest, left lateral
Encourage a well-balanced diet
Weigh daily, keep daily log
Education on self - assessment
Diversion
Family support
e. Post-delivery PIH
o with Disseminated Intravascular Coagulation - anticoagulant
therapy
o Monitor blood pressure for 48 hours
Diagnosis: Roll - over test : Assess the probability of developing toxemia when done
between the 28th and 32nd week of pregnancy.
f. Cathartic - cause shift of fluid from the extracellular spaces into the
intestines from where the fluid can be excreted
Dosage:
deep IM,
ml D10W),
10 gms initially -either by slow IV push over 5 - 10 minutes or
3. DIABETES MELLITUS
a.
b.
c.
Chronic hereditary disease characterized by marked hyperglycemia
Due to lack or absence of insulin _
metabolism
abnormalities in CHO, fat and protein
d.
Effects of pregnancy - may develop abnormalities in glucose tolerance decreased
renal threshold for sugar due to increased estrogen, inc. production of
adenocorticoids, Anterior Pituitary hormones, and thyroxin which affect CHO
concentration in blood (hyperglycemia)
Rate of insulin secretion is increased but sensitivity of the pregnant body to insulin
is decreased
Pregnancy Risks:
1
2
3
4
5
6
7
Toxemia
Infection
Hemorrhage
Polyhydramnios
Spontaneous abortion - because of vascular complications
which affect placental circulation
Acidosis - because of nausea and vomiting
Dystocia - due to large baby
Diagnosis : Glucose Tolerance Test (GTT)
Interpretation of Results:
a. If less than 100 mg% = normal
b. If 100 - 120 mg% possible GDM
c. If more than 120 mg% - overt gestational diabetes
Management:
a.
b.
c.
d.
Diet - highly individualized- adequate glucose intake (1,800 -
2200 calories) to prevent intrauterine growth retardation
Insulin requirements - individualized; increased during 2nd
and 3rd trimester because of more pronounced effect of
hormones
Method of Delivery - Cesarian Section
b.
c.
d.
e.
f.
g.
h.
Typically longer and weighs more due to: excessive supply of
glucose from the mother
Increased production of growth hormone from maternal pituitary
gland
Increased secretion of insulin from the fetal pancreas
Increased action of adrenocortical hormone that favor the passage
of glucose from mother to fetus congenital anomalies are often
seen
Cushingoid appearance (puffy, but limp and lethargic)
Born premature more often - RDS common
Greater weight loss because of loss of extra fluid
Prone to hypoglycemia (BG <30 mg%)
Signs and symptoms of Diabetic Babies/ Hypoglemic Infant:
a.
b.
c.
d.
e.
Shrill, high pitched cry
Listlessness/jitteriness/tremors
Lethargy/poor suck
Apnea/cyanosis
Hypotonia; hypothermia
***Consequence of hypoglycemia: untreated hypos _ brain damage and even death
***Management: feed with glucose water earlier than usual, or administer IV of glucose
4. HEART DISEASE
Classification:
Class I
Class II
Class III
activity causes fatigue
Class IV
- no physical limitation
- slight limitation of physical activity
- Ordinary activity causes fatigue, palpitation, dyspnea, or angina
- moderate to marked limitation of physical activity; less than ordinary
Congestion of liver and other organs due to inadequate venous return _ increased
venous pressure _ fluid escapes through the walls of engorged capillaries and cause edema
and
ascites CHF is a high probability due to increased CO during pregnancy _ dyspnea,
exhaustion, edema, pulse irregularities, chest pain on exertion and cyanosis of
nailbeds are obvious
5. MULTIPLE PREGNANCY
Management:
a. Monitor FHT, VS, weight
b. Cesarean Section
c. Health Teaching on importance of regular pre-natal check-up visits
d. Educate regarding proper nutrition and exercise
6. BLOOD INCOMPATIBILITY
- An antigen-antibody reaction which causes excessive destruction of fetal red blood
cells
Mother
Rh- negative
BloodType O
Fetus
Rh Positive (Father is homozygous
or heterozygous Rh positive)
Either Type A or B (From father)
7. DYSTOCIA - broad term for abnormal or difficult labor and delivery
7.3. Uterine Inversion - fundus is forced through the cervix so that the uterus is
turned inside out
- Insertion of placenta at the fundus, so that as fetus is
rapidly delivered, fundus is pulled down
- Strong fundal push, attempts to deliver the placenta before
signs of separation
-Management: Hysterectomy
8. INDUCED LABOR
- Stages of labor and birth occurs due to chemical or mechanical means which is
usually performed to save the mothe or fetusr from complications which may cause death
Indications:
Maternal - toxemia
Placental accidents
Premature Rupture Of Membrane
Fetal: DM - terminated at about 37 wks AOG if indicated
Blood incompatibility
Excessive size
Postmaturity
Prerequisites to Induce Labor :
No Cephalo- Pelvic Dislocation
Fetus is already viable >32 weeks AOG
Single fetus in longitudinal lie and is engaged
Ripe cervix - fully or partially effaced; Cervical Dilatation at least 1=2 cm
2. Amniotomy - done with Cervical Dilatation = 4 cm ; Check FHR and quality of amniotic
fluid
Nursing Considerations:
Monitor uterine contractions _ potential for rupture
Monitor flow rate regularly
Turn off IV with any abnormality in FHR or contractions
Watch out for complications: HPN, Antidiuresis
Prostaglandin administration: Route: oral or IV (never IM causes irritation);
effect is slower than oxytocin
9. INSTRUMENTAL DELIVERIES
a. Forceps Delivery
- Use of metal instruments to extract the fetus from the birth canal, when at +3 / +4 and
sagittal suture line is in an AP position in relation to the outlet (e.g. Simpson, Elliot, Piper for
breech presentation)
Purposes:
shorten second stage of labor because of fetal distress; maternal exhaustion;
maternal disease - cardiac, pulmonary complication
ineffective pushing due to anesthesia
prevent excessive pounding of fetal head against perineum (low forceps for
prematures)
poor uterine contraction or rigid perineum
Prerequisites:
Pelvis adequate, no disproportion
Fetal head is deeply engaged
Cervix is completely dilated and effaced
Membranes have ruptured
Vertical presentation has been established
The rectum and bladder are empty
Anesthesia is given for sufficient perineal
Relaxation and to prevent pain
Complications:
Forceps marks - noticeable only for 24 - 48 hrs
Bladder or rectal injury
Facial paralysis
Ptosis
Seizures
Epilepsy
Cerebral Palsy
a. Cesarean Section - birth through a surgical incision on the abdomen
Indications:
o Cephalo-pelvic disproportion (CPD)
passive
o Severe Toxemia
o Placental Accidents
o Fetal Distress
o Previous classic CS - done prior to onset of labor pains; scheduled birth
Types:
Advantages:
Minimal blood loss
Incision is easier to repair
Lower incidence of post partum infection
No possibility of uterine rupture
Preoperative Care
a.
b.
c.
d.
The patient is both a surgical and an OB patient
Check vital signs, uterine contractions, and FHR
Physical examination; routine laboratory tests; blood typing and cross
matching
Abdomen is shaved from the level of the xiphoid process below the
nipple line,
extending out to the flanks on both sides up to the upper thirds of the
thighs
e.
f.
Retention catheter is inserted to constant drainage to keep the bladder
away from
the operative site
Preoperative medication is usually only atropine sulfate.
No narcotics are given _ causes respiratory depression in the NB
Postoperative Care
a.
b.
c.
d.
e.
f.
Deep breathing, coughing exercises, turning from side to side
Ambulate after 12 hours
Monitor vital signs
Watch for signs of hemorrhage - inspect lochia; feel fundus (if
boggy, massage
with proper abdominal splinting and give analgesics as ordered)
Breastfeeding should be started 24 hrs after delivery
Most common complication: Pelvic thrombosis
10. OTHER RISK FACTORS:
10.1. Age:
- Maternal and infant mortality rates tend to be high in age below 15
and older
than 40 years
Adolescent pregnancy
Most common problems:
Toxemia
Advanced age
A precipitating factor in:
Placental accidents
Iron-deficiency anemia
Toxemia
Uterine atony or inertia
Varicosities; hemorrhoids
Low birth weight babies
Chromosomal Abnormalities like Down's
Syndrome / Trisomy 21 (associated
with menopause)
10.2. Parity - first pregnancy is the period of high risk
Multiparity G5 and above and age is over 40
10.3. Birth Interval - 3 months from previous delivery or more than 5 years
10.4. Weight
Pre-pregnant weight < 70 lbs or > 180 lbs
Weight gain < 10 lbs _ LBW babies
Weight gain > 30 lbs = sign of toxemia; DM; H-mole; polyhydramnios;
multiple
10.5. Height
pregnancy
Short stature < 4 feet, 10 inches = contracted pelvis or CPD
1. Spontaneous Abortion
Termination of pregnancy spontaneously at any time before the fetus has attained
viability
Assessment:
1. Persistent uterine bleeding and cramplike pain
2. Laboratory finding - negatively or weakly positive urine pregnancy test
3. Obtain history, including last
2. Ectopic Pregnancy
- Any gestation outside the uterine cavity
Management:
1. Curettage to completely remove all molar tissue that can become malignant
2. Pregnancy is discouraged for 1 year
3. hCG levels are monitored for 1 year (if continue to be elevated, may require
hysterectomy and chemotherapy)
4. Contraception discussed; IUD not used
4. Incompetent Cervical Os
One that dilates prematurely
Chief cause of habitual abortion ( 3 or more)
Causes:
1
2
3
Management:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Hospitalization, initially
Bedrest side-lying or Trendelenberg position for at least 72
hrs.
Ultrasound to locate placenta
No vaginal, rectal exam unless delivery would not be a
problem (if necessary must be done in OR under sterile
conditions)
Amniocentesis for lung maturity; monitor for changes in
bleeding and fetal status
Daily Hgb and Hct
Two units of crossmatched blood available
Monitor amount of blood loss
Send home if bleeding ceases and pregnancy is maintained
Limit activity
No douching, enemas, coitus
Monitor fetal movement
NST at least every 1 - 2 weeks
Monitor complications
15
7. Abruptio Placenta
(Occurrence increased with maternal HPN and cocaine abuse; sudden release of
amniotic fluid; short cord; advanced age; multiparity; direct trauma;
hypofibroginemia)
Management:
a. Monitor maternal and fetal progress
b. Blood loss seen may not match symptom
c. Could have rapid fetal distress
d. Prepare for immediate delivery
e. Monitor for post partal complications
Predisposing Factors:
b. Disseminated intravascular coagulation
c. Pulmonary emboli
d. Infection
e. Renal failure
f. Transfusion hepatitis
Nursing Intervention:
Bedrest
Vital signs, FHT
Monitor intake and output
Seizure precautions
Medications (Magnesium sulfate, Apresoline, Valium)
8. Uterine Rupture -occurs when the uterus undergoes more straining than it is capable of
sustaining
Management:
Emergency measures to maintain life: IV, oxygen, CPR
Provide intensive care in the ICU
Keep family informed
Provide emotional support
Management:
o If no bleeding; no CD, Good FHT, medication is given
Ethyl alcohol (Ethanol) IV - blocks release of Oxytocin
Vasodilan IV - vasodilator
Ritodrine - muscle relaxant per orem
Bricanyl - bronchodilator