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Unit 3 Table of Contents MA TERNAL & CHILD NURSING

Section I. Anatomy & Physiology 1. Reproductive System a. Female Reproductive System 1) External Genitalia 2) Internal Genitalia 3) Types of Pelvic Ligaments b. 2. 3. Male Reproductive System 1) External & Internal Features

Mammary Glands Reproductive Hormones a. b. Female Reproductive Hormones Other Reproductive Hormones


Menstruation a. b. c. d. e. Menstrual Changes Menstrual Cycle Ovarian Cycle Endometrial / Uterine Cycle Menstrual Disorders


Family Planning a. b. c. d. Natural Conception Barrier Methods Pharmacological Methods Birth Control Summary

Section II. Antepartal Period 1. 2. Assessment of Prenatal Risk Factors Physiological Changes in Pregnancy a. Physiological Changes b. Antepartum Health Promotion Fertilization to Conception a. Fertilization



b. Origin of Body Tissues Fetal Development a. Measuring Age of Gestation

5. 6. 7. 8. 9. 10. 11.

Maternal & Fetal Diagnostic Tests Electronic Fetal Monitoring Laboratory Studies Other Gynecological Procedures Three Common Pregnancy Signs Discomfort Signs of Pregnancy Psychological Changes in Pregnancy a. Maternal Changes in Pregnancy b. Paternal Adaptations in Pregnancy

Section III. Antepartal Complications 1. 2. 3. 4. 5. Abortion Ectopic Pregnancy H-mole Incompetent Cervix Diabetes Mellitus of Pregnancy

6. PIH (Pregnancy Induced Hypertension) 7. Bleeding Disorders in Pregnancy ( Table of Comparison)

a. Placenta Previa b. Abruptio Placenta 8. 9. Vena Cava Syndrome Diseminated Intravascular Coagulation

10. Hyperemesis Gravidarum Section IV. Intrapartum Care 1. Five Factors Affecting Labor (Table of Mechanics of Labor)

a. Passageway 1. Types of Pelvis 2. Pelvic Measurements b. Passenger 1. Fetal Attitude 2. Fetal Lie 3. Fetal presentation 4. Fetal Position c. Power 1. Three Phases of Contraction 2. Characteristics of Contractions d. Placental Factors e. Psyche 2. Labor a. b. c. Signs of Impending Labor Comparison of True & False Labor Stages of Labor 1. Stations of Presenting Part d. e. f. g. 4. 5. Anesthezia Obstetrical Procedures a. b. c. d. e. Preterm Labor PROM (Premature Rupture of the Membranes) Prolapse Cord Dystocia Infection Nursing Considerations during Labor & Delivery Nursing Care during labor Assessing Fetal Heart Rate Cardinal Mechanisms / Movements of Labor

f. g. h.

Precipitate Delivery Uterine Rupture Amniotic Fluid Embolism

Section V.

Complications of Labor & Delivery a. b. c. d. e. f. g. h. Preterm Labor PROM ( Premature Rupture of the Membranes) Prolapsed Umbilical Cord Dystocia Infection Precipitate Delivery Uterine rupture Amniotic Fluid embolism

Section VI. Postpartum


Postpartum Biophysical changes a. Lochia b. Uterus c. Uterine Involution d. e. Breast GI Tract


Post Partum Discomforts a. Perineal discomforts b. Episiotomy

c. Breast Discomforts 3. Post partum Discharge Teachings a. Breast feedings b.Burping & Feeding c. Psychological Adaptations

SECTION VII. Neonatal Care 1. Initial Physical Examination & Care of the Newborn a. b. c. d. 2. 3. 4. 5. 6. 7. 8. Assessment Implementation Vital Signs Body Measurement

Head to Toe Newborn Assessment Gestational Assessment Newborn Reflexes Basic Teaching Needs of New Parents Preterm Neonates Post term Neonates Other Newborn Abnormalities a. b. c. d. e. f. g. RDS (Respiratory Distress Syndrome) Hemolytic Disease Hyperbilirubinemia Erythroblastosis Fetalis The Newborn of Addicted Mothers SGA (Small Gestational Age) Nervous System Anomalies 1. 2. 3. Spina Bifida Meningocele Myelomeningocele


Section I

I.a External Genitalia (Vulva/Pudendum) MONS PUBIS -Soft fatty tissue, lies directly over symphysis pubis & becomes covered w/ hair just before puberty It is where the pubic hair grows.

LABIA MAJORA -W/ hair outside but smooth inside fatty skin folds from MONS PUBIS to PERINEUM and protects the labia minora , urinary meatus & vagina

LABIA MINORA -Thin, pink, smooth, hairless, extremely sensitive to pressure, touch and temperature. The glands of labia minora lubricate the vulva. It is formed by the frenulum and the prepuce of the clitoris which is also very sensitive because it has rich nerve supply.

Covers and protects VESTIBULE



TWO GLANDS THAT LUBRICATE DURING SEX 1. SKENES GLANDS (Paraurethral Glands): lubricates the external genitalia 2. Bartholins Gland (Vulvovaginal Glands): alkaline in ph, helps improve sperm survival Doderleins Bacillus: causes the vaginal ph to be acidic, which forms lactic acid Hymen: the elastic tissue, symbolizes virginity. Thorn & bloody during forced sexual act RUGAE: thick folds of membranous stratified epitheliums on the internal wall of the vagina, capable of stretching during the birth process, to accommodate the delivery of the fetus.

-Entrance of urethra, opens approximately 1cm below clitoris

-Composed of glans & shaft that is partially covered by prepuce -GLANS is small and round and is filled w/ many nerve endings and rich blood supply -SHAFT is a cord connecting the glans to the pubic bone; w/in it is the major blood supply of clitoris

Figure 1-a Internal Structure

Ib. Internal Genitalia

(Figure 1-a) ORGAN Uterus

FUNCTIONS Pear shape muscular organ which has three(3) main functions 1. receive the ova from the fallopian tube 2. provide a place for implantation of the ova 3. Nourishment for fetal growth.

STRUCTURE Divisions of the uterus I. Cervix : lowest portion , 1/3 of the total uterus External Os: where the nurse obtain the Pap Smear to the SQUAMOCOLUMNAR JUNCTION cells. This is where the cerclage is done for incompetent cervix. Namely: A. Shirodkar Barter Suture- permanent closure of the internal cervical os, until the 38th week after which is separated TREATMENT FOR INCOMPETENT CERVIX and PREVIOUS ABORTION. B. Mc Donalds or Purse String Cerclage of the external os: usually Normal spontaneous delivery will be done for the patient. II. Isthmus: shortest portion of the uterus, the portion that is cut when the fetus is delivered during cesarean birth. III. Fundus: Upper segment, this is the most vascular, the portion also where palpation is done. Also touching it by the tip of the fingers during contraction is the best method to determine the intensity of contractions during labor.

NOTES Layers of the Uterus: 1. Endometrium: inner layer, most vascular, SHED DURING MENSTRUATION.TH E NON-PREGNANT UTERUS 2. Myometrium: LARGEST PORTION EXPELS THE FETUS DURING THE BIRTH PROCESS. The part that contracts during hemorrhage. Prevents hemorrhage. 1. Perimetrium: Outer most layer. Aids for support & added strength.

Bandls Ring ( Pathological Retraction Ring): seen in Prolonged Labor or Dystocia

Fallopian tubes

Site of fertilization of the ovum with perm


Ovulation (the release of an ovum); Steroid hormone production

4 Parts of the Fallopian tubes 1. Interstitial : lies within the uterine wall 2. Isthmus: the portion that is cut or sealed in TUBAL LIGATION ( site for sterilization) 3. Ampulla: where fertilization occurs , this is also the LONGEST portion, frequent site for ectopic pregnancy. 4. Infundibular: covered by the Fimbriae cells that help guide the ova to the Fallopian Tube. Pair of follicle containing organs on the other side of the uterus Ovaries: 4 by 2 cm in diameter, 1.5 cm thick. Responsible for the production, Maturation, and discharge of ova Secretion of estrogen and progesterone Cortex of the Ovaries; developing and graafian follicles are found here. Tube extending from the introitus to cervix

Fallopian tubes transport the ova from the ovaries to the uterus.

The ovaries lie in the upper pelvic cavity.


Organ for coitus; Birth canal; Conduit for menstrual flow.

Fibromuscular lined with membrane

organ mucus

I c. Types of Pelvic Ligaments 1. Round: remain lax during non-pregnancy & become HYPERTROPHIED & elongated during 2. 3.
pregnancy. Cardinal: chief uterine supports Broad ligaments: drapes over the fallopian tubes, uterus & ovaries

I. B
External Features: 2 Erectile Tissues in the penis: a. Corpus cavernosa b. corpus spongiosum Internal Features:


Epididymis: totals 20 ft. WHERE SPERMS ARE STORED Vas / Ductus Deferens: carries the sperm to the inguinal canal Seminal Gland / Vesicle: Secretes SEMEN Prostrate Gland: secretes SEMEN also. Cowpers Gland/ Bulbo-urethral: secretes also semen SEMEN sources: 1. prostrate gland : 60% 2. Seminal vesicles : 30% 3. Epididymis : 5% 4. Cowpers : 5%


Accessory Structures

Figure 1-b Mammary Glands

III. Mammary Glands

MAMMARY GLANDS -2 mammary glands located on each side of chest wall -Each breast 15-20 lobes containing clusters of ALVEOLI

ACINI -Saclike end of the glandular system -Lined both w/ epithelial cells that secrete colostrum( whic h is rich in IgA) & milk & w/ muscles that expel milk

DUCTULES -Exit alveoli & join to form larger canals LACTIFEROUS DUCTS -During lactation, milk flows to the alveoli and then thru the duct system further going to the balloon like storage sacs called LACTIFEROUS SINUSES

NIPPLES -Sinuses merge into openings on nipple


IV. Female Reproductive Hormones HORMONES

Follicle Stimulating Hormone *Stimulates Graafian follicle to mature and resulting in increase levels of estrogen

smooth muscles Inhibits the secretion of FSH b. Respo nsible for the increase vaginal secretion in the vagina (LEUKORRHEA) c. Thickens the endometrium d. SUPPRE SSES THE FSH & Prolactin e. Responsi ble for the devt of 2ndary sex characteristics in females f. Stimul ates uterine contractions & smuscular peristalsis of the fallopian tubes for the passage of the ovum to the uterus. g. Mildly increases Na & water reabsorption h. Stimul LUTENIZING HORMONE AND ESTROGEN peak immediately before ovulation

Lutenizing Hormone -When follicle is ripe and mature, triggers follicular rupture and release of ovum -Peaks at 16-18 hours before ovulation. -stimulates ovulation & development of corpus luteum

Estrogen -Produce from ovaries, adrenal cortex, and placenta -Assists in maturation of Graafian follicle -Stimulates thickening of endometrium. Other functions

Progesterone *Produce from corpus luteum, placenta -Secretes thick/viscous cervical secretions. A.Preparation of the uterus to receive a fertilized ovum B. Decrease uterine motility/ contractility during pregnancy C. Increases basal metabolism D. Enhances placental growth E. Stimulates the devt of acini cells in the breast(major cells for breast milk) Increase the endometriums supply of glycogen, oxygen & amino acids for maintaining pregnancy

a. Contracts

Most women ovulate two weeks before the beginning of the next period.


IV a. Other Reproductive Hormones

1. Lactogenic Hormone (Prolactin) -Stimulates lactation 2. Melanocyte Stimulating Hormone -Responsible for the linea nigra & chloasma in pregnancy -Secreted by the anterior pituitary hormone MELANOTROPIN -Will end on the 2nd month of pregnancy 3. Human Chorionic Gonadotropin -Increases in nausea and vomiting Responsible for Hyperemesis Gravidarum

Menarche: 1st menstrual period, usually age 12, but may begin as early as 9. Menopause: cessation of menstrual cycle that occurs normally from 40 & 55 y.o. Menstrual Cycle: 1. Menstrual Phase ( 1 14 days) -Corpus luteum dies. -Progesterone & Estrogen vanishes- triggers/stimulate the production of FSH. -Endometrium degenerated/ sheds- menstruation occurs. Sexual intercourse during menstruation is not harmful.

2. Proliferative Phase- Estrogen Phase ( 6 14 days) Graafian Follicle: Estrogen

Anterior Pituitary Gland secretes FSH stimulates the development of the Graafian follicle (secretes Estrogen) suppresses FSH & stimulates LH LH stimulates ovulation Increase Estrogen kills/decreases FSH 3. Secretory Phase (15 to 21 days) Progesterone Phase (Corpus Luteum: Progesterone) Other Books it is called: Luteal Phase After Ovulation-----release of mature ovum from the Graafian follicle-----Graafian Follicles die and replaced by Corpus Luteum-----secretes progesterone Functions of Progesterone: 4. Pre-Menstrual Phase (22 days to 28 days) -If fertilization does not occur, corpus luteum begins to die -Progesterone & Estrogen decreases -Endometrium degenerates -Menstruation stops during pregnancy because there is decrease secretion of hormones by the ovary.






FOLLICULAR PHASE Ovarian follicles mature under influence of FSH and estrogen LH surge causes ovulation -mittelshmerz -cervical changes -increase BBT


ENDOMETRIAL/UTERINE CYCLE (Described by varying thickness of the endometrium) (Figure 1-c) MENSTRUAL PHASE -Menstruation -Decrease estrogen -Decrease progesterone PROLEFERATIVE PHASE -Hypothalamus secretes FSH -APG (anterior pituitary gland) secretes FSH -Maturation of Graafian follicle -Increased estrogen -Hypothalamus stops FSH & starts LH -APG stops FSH & starts LH secretion SECRETORY PHASE -Formation of corpus luteum -Increase progesterone -NO FERTILIZATION; corpus luteum degenerates 10 days after ovulation -WITH FERTILIZATION; concepts produces HCG that sustains life corpus luteum; progesterone level is maintained at high level -Progesterone level decreases -Corpus albicans Sloughing off of endometrial lining PREMENSTRUAL PHASE -endometrium degenerates


Figure 1-c Menstrual Cycle

V. a Menstrual Disorders
Dysmenorrheal - PrimaryNo known cause - SecondaryMay be caused by tumor/inflammat ory conditions Premenstrual Syndrome -Edema of lower extremities - Abdominal bloating - Weight gain - Headache -Breast tenderness - Depression - Crying - Loss of concentration Amenorrhea PrimaryNever menstruated; structural/congeni tal abnormality Secondary Cessation of menstruation Menorrhagia -Excessive prolonged bleeding or Metrorrhagia - Irregular bleeding in between periods

VI. FAMILY PLANNING AND CONTRACEPTION Family Planning Methods The most important topic in a Prenatal Visit is the DANGER SIGNS IN PREGNANCY!! Discharge planning should start 0n the admission to the facility: to introduce to the community & support services!!! #1 Initial Responsibility of a Nurse in Pregnant Adolescents is to impress the importance of Prenatal care: cause they are often PRONE to PIH devt factors such as -( age, diet & lack of prenatal care) Before counseling a patient about contraceptive methods, the nurse must: EVALUATE HER OWN BELIEFS & VALUES REGARDING FAMILY PLANNING!!!!


Natural or Fertility Awareness Methods A. Natural Contraceptives 1. Billings Method (Cervical Mucus): with ovulation (peak day) the mucus becomes thin and watery, transparent, CLEAR, THIN & ELASTIC- avoid having sex in this phase). SPINNBARKEIT. Greatest Factor for Basal Body Temperature DISTURBANCE---will be the presence of stress. 2. Calendar Method: to determine her FERTILITY, subtract 18 days from the SHORTEST MENSTRUAL CYCLE & 11 days from her longest cycle. 3. Daily Basal Body Temperature: will drop from 0.2 0.8 degrees Fahrenheit during ovulation in response to PROGESTERONE. Dont have sex on the 1st day of menses unt6il 3rd day of temperature elevation. Monitor for at least 3 months before analyzing the results!!!! Most accurate reading, immediately after awakening, before arising!!!! 4. Sympto thermal: mixture of Cervical Mucus & Basal Body Temperature 5. Coitus Interruptus : oldest & least effective method. Natural methods of birth control generally have a higher failure rate because it depends on knowing when the ovulation occurs, since this is difficult to accurately determine, the chance of miscalculation is high. The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse. CALENDA R METHOD Relies on abstinence from intercourse during fertile period BASAL BODY TEMPERATURE * Measured by taking & recording e temperature rally rectally each morning before waking after at least 3 hours of sleep * Drops before ovulation and rises 0.2 F-0.8 F In Basal body temperature method the patient should take her temperature every morning upon awakening and prior to any activity to avoid the temperature being influenced CERVICAL MUCUS METHOD * Uses the appearance, characteristics and amount of cervical mucus to identify ovulation Ovulatory: cervical mucus is clear and abundant Pre-ovulatory / post ovulatory: cervical mucus is yellowish, less abundant, and sticky (inhibit sperm motility) . SYMPOTHE RMAL METHOD * Couple makes use of combination of calendar, BBT, and cervical mucus method to determine fertile period MITTELSCHMERZ COITUS INTERRUPTS * Requires withdrawal of the penis from the vagina before ejaculation

* Between menstrual cycles, some women experience pain when the ovary releases egg * Rarely accompanied by scant vaginal spotting * Some couple uses this as signal of the beginning period and to avoid sexual intercourse until the fertile period passes


by other factors.

B. Barrier Methods FEMALE CONDOM (VAGINAL POUCH) - Long polyurethane sheath that is inserted manually into vagina with a flexible internal ring extending to cover the perineum - Lubricated with a spermicide (non-oxynol-9) - It can be inserted up to 8 hrs before intercourse MALE CONDOM - Rubber sheath that fits over the erect penis and prevents sperm from entering the vagina IUD -Flexible device inserted into the uterine cavity -It alters uterine transport of the sperm so fertilization dont occur DANGER SIGNS TO REPORT: - Late or missed menstrual period -Severe abdominal pain -Fever and chills - Foul vaginal discharge -Spotting, bleeding, or heavy menstrual periods - Spontaneous expulsion occur in 2%-10% of users in the first year

Figure 1-d Condom

NCLEX TIPS!! The female condom during sex Figure 1-d During sex the penis is inserted into the center of the open ring at the opening of the vagina. Until both partners are familiar with the Reality condom, the penis should be guided by hand into the open ring. Otherwise there is the chance that the penis will be inserted outside the condom into the vagina, thus defeating the condom's purpose. Use of the male condom with the female condom is not recommended, because rubbing the latex male condom against the polyurethane female condom creates friction that may make intercourse difficult. Removing the female condom The female condom should be removed following intercourse and before standing up. To remove, squeeze and


twist the outer ring to ensure that semen remains inside the condom. Gently pull the condom from the vagina. Discard in the trash. Do not attempt to flush the condom down the toilet, as it may clog the toilet or sewer lines. Do not reuse. Important points to remember when using the female condom - The female condom works only if you use it every time you have sex. - Use a new condom each time you have sexual intercourse. Do not reuse the female condom. - You can still become pregnant and transmit or acquire a sexually transmitted disease while using the female condom. The risk is less than if you do not use the condom, but there still is a slight risk. - Although the Reality condom is prelubricated, it also comes with a tube of lubricant in the package. You may wish to add a few drops of lubricant to the opening of the condom or to the penis. Lubricants reduce friction and noise those results from friction. - Remove tampons before inserting the female condom. - Use caution to avoid tearing the female condom with a sharp fingernail, ring, or other jewelry when inserting and removing the condom. CERVICAL CAP VS DIAPHRAGM CHARACTERISTICS DESCRIPTION EFFECTIVITY USAGE SPERMICIDE SIDE EFFECTS Fitted by health provider HOW TO INSERT Not longer than 48 hours DURATION CERVICAL CAP Small rubber plastic that fits snugly over cervix NULLIPARA=80% MLTIPARA=60% Continuous protection 24 hours regardless of the number of times of sexual intercourse Not necessary for repeated coitus Cervicitis DIAPHRAGM (Figure 1-e) Flexible ring covered with dome shape rubber cap 80% with typical use On two hours prior to sexual intercourse and in place for 6 hours after Use every coitus Cystitis, cramps, rectal prolapsed Toxic Shock syndrome (TSS) Same, refitted after birth and weight loss of 15lbs Not longer than 24 hours A diaphragm should be left in the vagina 6-8 hours after sexual intercourse.

Diaphragm: should remain in place 6-8 hours after sex & maybe left for 24 hours. ALWAYS CHECK FOR TEARS & HOLES!!! Contraindicated for: Frequent UTI, Prolapsed Cord & Retroverted Uterus, cystocele & rectocele, acute cervicitis


Figure 1-e Diaphragm C. Pharmacologic methods Oral Contraceptive Pill: synthetic estrogen combined with small amounts of synthetic progesterone-preventing ovulation by stopping FSH & LH. - Stops LH & FSH STOP IF WITH THE FF: (ACHES) - A- abdominal pain, C- Chest pain, H- Headaches, E- eye problems & S-severe leg cramps - ATTN: Severe Headaches maybe an indication of Hypertension!!!! CONTRAINDICATED: 1 Thromboembolism 2 CVA, HPN, smoking & diabetics,DIC, hyperviscosity Contraindicated for DIABETICS. The best for diabetics are Barrier Contraceptives--Condom & Diaphragm Examples: Demulen (Ethinyl Estradiol Ethylnodiol ) a monophasic oral contraceptive agent. If the patient forgets to take 2 tablets for the next 2 days, she should take 2 tablets NEXT 2 DAYS!!! And use another contraceptive method for the rest of the cycle. If she misses 3 or more, she should discard the remaining tablets & use another contraceptive method for the rest of the cycle. ORAL CONTRCEPTIVES Use to prevent conception by inhibiting ovulation (inhibits release of FSH and LH) Causes atrophic changes in the endometrium to prevent implantation of egg Causes thickening of cervical mucus to inhibit sperm travel MINIPILLS Pills contain progestin but no estrogen Pills must be taken each day and preferably same time each day to achieve maximal effectiveness Thins and atrophy endometrium and thickens cervical SUBDERMAL IMPLANTS Six soft sillastic rods filled with synthetic progesterone implanted into the womans arm Progesterone leaks into the blood stream, inhibiting implantation into endometrium Norplant Inserted subdermally SUBCUTANEOUS INJECTIONS Medroxyprogesterone (DMPA or DEPOVERA)


Under ideal conditions the sperm can reach the ovum 1 to 5 minutes after ejaculation. Combined estrogen and progesterone preparation in tablet form and are taken daily with combinations of hormones Oral contraceptives prevent pregnancy by suppressing FSH (follicle stimulating hormone) and LH (leutenizing hormone) release from the pituitary gland thereby blocking ovulation.

mucous ADVANTAGE: can be use immediately postpartum if client is not breastfeeding and 6 weeks if breastfeeding Women taking the minipill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female hypogonadism, and premenstrual syndrome aren't associated with progestin-only oral contraceptives.

into the midportion of the upper arm about 8-10cm above the elbow crease. 6 implantable capsules are inserted at one time

Birth Control Summary Table RISKS OR POSSIBLE PROBLEMS



Spermicides: chemicals in the form of foams, creams, jellies, Available Only partially effective films, or suppositories that are inserted into the vagina to kill over the against sexually sperm before they can enter the uterus; typical use effectiveness: counter transmitted disease 70% Can be used (STD) transmission with other Possible allergies or methods to irritation improve effectivenes s Condom: male condom is a sheath of latex or animal tissue Effective Possible allergies to placed on erect penis; female condom is a plastic sac with a ring against latex or spermicide on each end inserted into the vagina; both may be used with a STD Lessens sensation spermicide; typical use effectiveness: 84% (male) 79% (female) transmissio May break during n intercourse Available .Avoid using petroleum over the jelly of oil base counter products; it can cause Can be used INCREASE FRICTION with other which will lead to methods to TEARING OF THE further LATEX CONDOM. protect against STD


Diaphragm: shallow latex cup with flexible rim inserted into vagina over cervix to prevent sperm from entering uterus; used with spermicide; typical use effectiveness: 82%

Reusable Not effective against Can last for STD transmission one to two Needs to be fitted by a years health care professional Increased risk of bladder infection Possible allergies to latex or spermicide

Cervical Cap: thimble-shaped latex cap inserted into vagina over Reusable Not effective against cervix to prevent sperm from entering uterus; used with Can last for STD transmission spermicide; typical use effectiveness: 82% one to two Needs to be fitted by a years health care professional Difficult to fit women CERVICAL CAP: can be retained upto 48 hours. It does not with an unusual cervix leak. Cannot be re-applied again after use. May use spermicide size before use. Difficult for some women to insert Birth Control Pill: prescription drug containing female hormones; one pill taken daily prevents ovaries from releasing eggs and/or thickens cervical mucus to prevent sperm from reaching egg; typical use effectiveness: 94% More Not effective against regular STD transmission periods Rare but dangerous No action complications, required including blood prior to clotting and sexual hypertension, intercourse, particularly in women permits over 35 years who sexual smoke spontaneity Must be taken daily Some protection against ovarian and endometria l cancer, noncancer ous breast tumors, ovarian cysts

Hormonal Implant (Norplant): six small capsules inserted by a Protects Not effective against health care professional under the skin of upper arm that deliver against STD transmission small amounts of hormone to prevent ovaries from releasing pregnancy Possible scarring or, egg; typical use effectiveness: 99% for up to rarely, infection at five years insertion site No action Side effects include required irregular bleeding, prior to headaches, nausea, sexual depression intercourse, permits sexual spontaneity Can be


used while breastfeeding beginning six weeks after delivering baby Hormonal Injection (Depo-Provera): injection given by a health Protects care professional in the arm or buttock every 12 weeks to against prevent ovaries from releasing an egg and/or thicken cervical pregnancy mucus to keep sperm from reaching an egg; typical use for 12 effectiveness: 99% weeks No action required prior to sexual intercourse, permits sexual spontaneity Can be used while breastfeeding beginning six weeks after delivering baby Protects against cancer of the uterine lining and iron deficiency anemia Intrauterine Device (IUD): small device inserted by a health care Effective professional into the uterus; prevents eggs from being fertilized one to six and/or implanting in uterus; typical use effectiveness: 96% years, depending Intra-uterine Devices (IUD)- a small plastic object is on type inserted into the uterus where it remains in place. It interferes used with the ability of the ovum to develop as it transverses the No action fallopian tube. required Most Frequent Side Effect: prior to a. Excessive Menstrual flow (menorrhagia) b. Spontaneous sexual Expulsion of the device: Myometrium irritability c. intercourse, Cramping & fever permits Contraindications: sexual spontaneity 1. History of PID: a woman using IUD has 50% chance of getting PID. 2. Ectopic Pregnancy, AIDS Not effective against STD transmission Side effects include irregular bleeding, weight gain, headaches, depression, abdominal pain Side effects do not reverse until medication wears off May cause delay in becoming pregnant after injections are stopped

Not effective against STD transmission May cause spotting between periods and longer, heavier periods Increased risk of pelvic inflammatory disorder(PID) within first four months after insertion Rare risk of uterine perforation


Never use / give IUD to NULLIPAROUS WOMEN!!! Return to the clinic for evaluation after her 1st menses!!!

Figure Intra uterine device (IUD)

Tubal Ligation: surgical procedure to permanently block woman's Fallopian tubes to prevent eggs from reaching sperm; typical use effectiveness: 99%

Permanent protection from pregnancy No action Tubal ligation: isthmus part in the fallopian tube is the usual required part being lighted. prior to sexual intercourse, permits sexual spontaneity

Not effective against STD transmission Reactions to surgery may include infection, bleeding, injury to intestine, reaction to anesthesia Increased chance of ectopic pregnancy Irreversible

Vasectomy: surgical procedure to permanently block the male's Permanent Not effective against vas deferens to prevent sperm from reaching eggs; typical use protection STD transmission effectiveness: 99% from Reactions to surgery pregnancy may include infection, blood clot near testes, Surgical sterilization of the male involves cutting the ductus No action required bruising, swelling, or deferens. prior to tenderness of scrotum sexual Irreversible Vasectomy: Vas Deferens is cut. The man can resume intercourse, sex after one week or when the sperm count indicates 0 permits count or 2 negative sperm count have been examined. sexual spontaneity Generally it requires 6 36 ejaculations to render neg. sperm count In order to get for semen analysis, collect them in a clean glass not plastic, because it


may affect the spermatozoa. No sex for 3 days before the semen collection & no drinking of alcohol for 1 day. The first portion of the semen has a high ration of sperm. Natural Family Planning: techniques, including checking body temperature or cervical mucus daily or recording menstrual cycles on a calendar, to determine the days when body is most fertile; typical use effectiveness: 81% No medical Not effective against or hormonal STD transmission side effects Requires strict Inexpensive recordkeeping Accepted Illness or lack of sleep by most may affect body religions temperature Vaginal infections and douches may affect cervical mucus Requires abstinence from sexual intercourse or alternative contraception during fertile days

Section II Antepartum Period

I. Assessment of Risk Factors in the Prenatal Period
Age of Pregnant Women -17 below: Have a higher incidence of 1. Prematurity 2. Pregnancy Induced Hypertension 3. Cephalopelvic Disproportion Women over 35 years old are at Risk for: 1. Chromosomal Disorders in infants 2. PIH 3. Cesarean Delivery Primigravida - 1st time Pregnancy Primipara - 1st delivery of a live infant, Nulligravida - never been pregnant Infections: Use TORCH T O R C H Toxoplasmosis Other infections Rubella Cytomegalovirus Herpes

A. Toxoplasmosis (protozoa)


Produces symptoms of acute, flu-like infection in mother Transmitted through raw meat or handling cat litter of infected cats Spontaneous abortion likely to occur early in pregnancy B. Rubella Extremely teratogenic in first trimester Causes congenital defects of eyes, heart, ears, and brain Women with low rubella titers should be vaccinated at least 3 months before becoming pregnant or following a delivery NOTE: Any woman in the first trimester of pregnancy is at risk if exposed to rubella. Congenital Fetal defects often results from such an infection. C. Cytomegalovirus (CMV) .Produces flu-like or mononucleosis-like symptoms in the mother Transmitted through the respiratory or sexual route May cause fetal death, retardation, heart defects, deafness No effective treatment available D. Herpes Simples Affects the external genitalia, vagina, and cervix Causes draining, painful vesicles Delivery of the fetus is usually by cesarean section active lesions are present in the vagina; delivery may be performed vaginally if the lesions are in the anal, perineal, or inner thigh area (strict precautions are necessary to protect the fetus during delivery) No vaginal examinations are done in the presence of active vaginal herpetic lesions Maintain CONTACT isolation procedures during hospitalization if the disease is active Neonate and mother may be separated during the active period, or other special precautionary measures may be used to avoid transmission to neonate

Teratogenic Drugs: BASA-O(code) B - Barbiturates A - Anti-malarial S - Salicylates A - Anesthetic O - Oral hypoglycemics Substance Abuse: Alcohol: causes learning disabilities, Mongolism, fetal alcohol syndrome Nicotine: increases vasoconstriction, retardation, SGA (small gestational age), low birth weight Heroin addict: babies are born with an EXAGGERATED/ HYPERACTIVE CNS / REFLEXES or CNS IRRITABILITY. Coccaine: The effect of cocaine in a labor and the fetus is preterm labor thus increased uterine contractions, intrauterine growth retardation and the potential for a sick, addicted infant

II. Physiological Changes in Pregnancy


Increases during pregnancy Increase Heart Rate for 10-15 beats/minute Increase Cardiac Output for 20% - 30% during 1st 2nd trimester to meet increase tissue demand Increase secretion of sugar (Glycosuria) INCREASE PLAMA VOLUME Increase Urinary Frequency due to pressure to bladder. Increase normal dependent Edema (bilateral or ankle edema) normal for 36 weeks gestation. Decreases during pregnancy Decrease (slightly of blood pressure) in the 2nd trimester due to decrease peripheral resistance Decrease Hemoglobin & Hematocrit because of Iron Deficiency (Pseudo- ANEMIA) Decrease gastrointestinal motility & peristalsis due to displacement of the intestine & compression of the stomach. ---leading to CONSTIPATION. Decrease Urine Specific gravity: a result of increase Urinary Output. Others: Chloasma : Mask of pregnancy Leukorrhea: whitish vaginal discharge without signs of inflammation & itching. Operculum: formation of mucus plug in CERVIX to seal out bacteria. Lordosis: the Pride of Pregnancy Relaxin: responsible hormone for the softening of the pelvic cartilages. Produce by the corpus luteum, contributes to the waddling gait typically noted in pregnancy. Normal delivery blood loss: 300 400 ml of blood Cesarean Section: 800 1000 ml

II a. Antepartum Health Promotion

Prenatal Visit Schedule of visit if with no complications: a. Every 4 weeks, up to 32 weeks b. Every 2 weeks, from 32-36 weeks (more frequently if problems exist) c. Every week from 36-40 weeks Classifications of Pregnancy GRAVIDA number of times pregnant, regardless of duration, including present pregnancy. PRIMIGRAVIDA pregnant for the first time. It's important for the nurse to distinguish between a client who's having her first baby and one who has already had a baby. For the client who's pregnant for the first time, quickening occurs around 20 to 22 weeks. Women who have had children will feel quickening earlier, usually around 18 to 20 weeks, because they recognize the sensations. MULTIGRAVIDA pregnant for second or subsequent time. PARA number of pregnancies that lasted more than 20 weeks. NULLIPARA a woman who has not given birth to a baby beyond 20 weeks gestation. PRIMIPARA a woman who has given birth to one baby more than 20 weeks gestation. MULTIPARA a woman who has had two or more births at more than 20 weeks gestation. Note: Twins or triplets counted as 1 para. PRETERM newborn born before 37 weeks of gestation.


TERM newborn born after 37 weeks to 40 weeks of gestation. POST-TERM newborn born after 40 weeks of gestation. Parity (TPAL) T P A L NUTRITION 1st Trimester: 2 4 lbs gain / 30-35 calories/kg/day 2nd trimester: 1 lb per week / 200 calories/kg/day 3rd trimester: 1 lb per week/ 200 calories/kg/day Pregnant Women needs 300 extra calories PER DAY for adequate nutrition. A diet of 2500 calories per day An increase of about 500 calories per day is needed during LACTATION. Iron Deficiency Anemia is a result of PICA. Different types of Exercises Pelvic Floor Contractions (Kegels Exercise): Promotes perineal healing, increase sexual responsiveness, press stress incontinence. Done 50-100 times. Examples: Tightening & strengthening the muscles of the Vagina, rectum, perineum & then relax after. Efficient for Urinary Frequency & Hemorrhoids. Increase elasticity of the Pubococcygeus muscle. Abdominal muscle Contractions: prevent constipation in pregnancy, done in standing or lying position, strengthening the abdominal muscles. Pelvic Rocking: Relieves backache during pregnancy, done by tightening the buttocks & flattens the lower back against the floor for one minute.

Number of terms births, Number of premature births, Number of Abortions, Number of living children

A. Abdominal breathing ( during latent phase of Stage 1 Labor) 1. Used until labor is more advanced 2. The abdomen moves outward during inhalation and downward during exhalation 3. The rate remains slow, with approximately six to nine breaths per minute B. Pant-pant-blow( during Transitional Phase of Stage 1 Labor) 1. Used in advanced labor 2. A more rapid pattern, consisting of two short blows from the mouth followed by a longer blow 3. All exhalations are a blowing motion

III. Fertilization to Conception

Fertilization: the union of the ovum & sperm. determination. The start of Mitotic cell division & fetal sex


> Primary oocyte (immature ovum) contains Diploid number of chromosomes (46). > One oocyte contains a haploid (23) number of chromosomes after division. > Gamete (mature ovum): is a cell or ovum that has undergone Maturation & will be ready for fertilization. > One gamete carries 23 chromosomes. > A sperm carries 2 types of sex chromosomes. X & Y. > 400 million sperm cells in one ejaculation. > Functional Life of spermatozoa is 48 hours > XX= female, XY= male.

Figure 1-F Morula Process of Fertilization: After ovulation ovum will be expelled from the Graafian follicles ovum will be surrounded by Zona Pellucida (mucopolysaccharide fluid) & a circle of cells (Corona Radiata) which increases the bulk of the Ovum expelled from the Fallopian Tube by the Fimbriae (infundibulum). Sperms move by flagella & Penetrate the & dissolve the cell wall of the ovum by releasing a proteolytic enzyme (Hyaluronidase) After penetration Fusion will result to Zygote. Zygote migrate for 4 days in the body of the uterus (Mitosis will take place-Cleavage formation will begin) After 16-50 cell formation from mitosis, a mulberry & Bumpy appearance will follow morula (figure 1-F) ---after 3-4 days, the structure will be ball like in appearance which will be called Blastocyst. Cells in the outer ring are called Trophoblast (later it forms the placenta, responsible for the devt of placenta & fetal membrane; Cells in the inner ring are called Erythroblast cells (which will be the embryo). Terms to remember: Ovum: From ovulation to fertilization Zygote: From fertilization to implantation Embryo: From implantation to 5-8 weeks. Fetus: From 5-8 weeks until term The ovum is said to be viable for 24-36 hours. Sodium Bicarbonate- the frequent medication to alter the vaginal ph, decrease the acidity of the vagina so as to INCREASE THE MOTILITY OF THE SPERM.


Figure 1-G Fetal Membranes Fetal Membranes: membranes that surround the fetus, & give the placenta the shiny appearance. (Figure 1-G) 2 Layers: a. Amnion: shiny membrane on the 2nd week of Embryonic Development & encloses the Amniotic Cavity b. Chorion: Outer membrane that supports the sac of the amniotic fluid. Chorionic Villi: finger like projections from the chorion. This is the place where gases, nutrients and waste products between the maternal & fetal blood takes place. Amniotic Fluid: surrounds the embryo, contains fetal urine, lanugo from fetal skin & epithelial cells. Ph is 7. 2. Specific Gravity: 1.005 1.025 Normal Amount: 500 1000 ml. Oligohydramniosless than 300 ml. Polyhydramniosmore than 2000 ml. observe for Down syndrome & congenital defects Functions of Amniotic Fluid: a. Protects the fetus from changes in the temperature & cushion against injury. b. Protects the umbilical cord from pressure, the fetus drinks & breaths the fluid into the lungs. Amniotic Fluid Colors: Normal color: transparent, clear, with white tiny specks Dark amber or yellow: Ominous sign of presence of Bilirubin, hemolytic disease Port Wine Colored: Abruptio Placenta Greenish: Meconium Stained / FETAL DISTRESS: always go for Cesarian Section! Also if ph is less than 7.2 If with odor: deliver within 24 hours, may indicate infection. Umbilical Cord: 21 inches in length & 2 cm in thick ness, circulatory communication of the fetus to the mother. CONTAINS 2 ARTERIES & 1 VEIN. Covered by a gelatinous mucopolysaccharide called Whartons jelly. Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium. During the 2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the 3rd week of development (21 days after implantation), the


embryonic disk evolves into three layers, and three new structures the primitive streak, notochord, and allantois form. Early during the 4th week (28 days after implantation), cellular differentiation and organization occur.

Figure 1-H Fertilization Cycle Table Summary from Fertilization to Implantation (Figure 1-H)

PRE-FERTILIZATION ACTIVITIES Ovum moves to amulla of fallopian tubes Capacitation Acrosome reaction

CONCEPTION Zona reaction

IMPLANTATION Morula (after 34 days implantation) Blastocyst (trophoblast; embryolast) Implants complete w/n 7-10 days

Zygote (fertilized ovum; about 24-48 hrs, divides; cleavage divides, travels to the uterus


Tissue Layer ECTODERM Mesoderm Endoderm Body Portion Formed Nervous system, mucus membranes, anus & mouth Connective Tissue, Reproductive, circulatory & upper Urinary system, bones, cartillage lining of the GI tract, Respiratory Tract, bladder & urethra

MULTIPLE PREGNANCIES Double ovum Single Ovum Dizygotic/fraternal twins Monozygotic/identical twins Ova from same or different ovaries union of a single ovum & a single sperm Same or different sex same sex one placenta


2 placentas but maybe fused 2 chorions & 2 amnions Genetics: Phenotype: Genotype: Karyotype: Serotype:

one chorion & 2 amnions

Individuals outward appearance Individuals Genetic Make up Pictorial analysis of individuals chromosomes antigenic character ABO

Genetic Disorders: Autosomal Recessive Disorders: both men & women are at equal risk because the DEFECTIVE GENE is an AUTOSOME: one of 22 pairs of non-sex chromosomes. Offspring of each pregnancy has a 25% chance of being affected and 50% chance of being a carrier. Examples are: PKU ( phenylketenuria) , Tay - Sachs Disease, Cystic Fibrosis, Thallasemia, and Sickle Cell Anemia Autosomal Dominant: an affected offspring has an affected parent. Examples are: Huntintons Chorea and Marfans Syndrome (Arachnodactyly)

X-linked dominant/Recessive Disorders: abnormal gene is found on the X chromosome because men have only one X chromosome, they always express the disorder. Examples are: Hemophillia and Duchenne Muscular Dystrophy


Figure 1- H2 Fetal Development


1 mo/ 4 weeks

2 mo/ 5-8 weeks

3 mos./9-12 wks

4 mos. /13-16 weeks

Embryo is 4-5 mm length Trophoblasts embedded in deciduas Foundations for nervous system, genitourinary system, skin, bones, and lungs are formed Rudiments of eyes, ears, nose appear Cardiovascular system functioning, heart beginning to beat, beginning of heart circulation. Placenta devt. Placental transport of substances ( 5 weeks) The fetus is 27-31 mm and weighs 2-4 grams Fetus s markedly bent Head is disproportionately large due to brain development Centers of bone begin to ossify Ganglionic cells (5th to 12th weeks) Placenta and meconium are present, with facial features CVS done (8 12 weeks) every organ present, Head greatly enlarged Average length is 50-55 mm and weighs 45 gms. Fingers and toes are distinct. Placenta is complete. Rudimentary kidneys secrete urine. Fetal circulation is complete. External genitalia show definite characteristics. Ganglionic cells SEX IS VISUALLY RECOGNIZABLE. Heart is audible in a Doppler ( 11th week) Fetus swallows. With nails. Kidneys able to secrete. 94-140 mm length and weighs 97-200 gms. Head is erected, lower limbs are well developed. Heartbeat is present Nasal septum and palate close Fingerprints are set LANUGO APPEARS IN THE BODY gms. Fetus is 150-190 mm. In length and weighs approximately 260-460

5 mos. /17-20 weeks

Lanugo covers entire body. Eyebrows and scalp hair is present. Heart sounds are perceptible by auscultation. Vernix caseosa covers skin. Heartbeat can be heard in the fetoscope ( 18 weeks20 weeks). Liver is already pancreas functioning. Quickening felt by a mother. Skeleton begins to develop. Brown Fats begin to form. Heart sounds in the stethoscope Can be heard ( 17- 20 weeks) NOTE: There is a placental barrier to syphilis until the 18 th week of pregnancy. If the mother is treated before 18 th week, the baby will most likely not be affected. 6 mos. /21-25 weeks 21-25 WEEKS OLD MANs FACE Length 200-240 mm. Wt. 495-910 gms. Skin appears wrinkled and pink to red. REM begins Eyebrows and fingernails develop.


7 mos. /26-29 weeks

8 mos. /30-34 weeks

9 mos. /35-37 weeks

10 mos. / 38-40 weeks

VERNIX COVERS THE ENTIRE BODY. Has the ability to hear. Production of lung surfactants. Passive Antibody transfer ( placental immunoglobulin G) Sustained weight gain occurs. Length 250-275; weight 910-1500 gms. Skin red Rhythmic breathing occurs Pupillary membrane disappears from eyes. Fetus often survives if born prematurely Brain develops rapidly. Lecithin- Sphingomyelin (L/S ratio is already 2:1) Brains fully developed. If born, neonate may survive. Length 280-320 mm. weight 1700-2500 gms. Toenails become visible Steady weight gain occurs Vigorous fetal movement occurs. LANUGO DISAPPEARS. Bones are fully developed. Aware of sounds outside the body. Assumes the delivery position. Increased chance of survival. Length 330-360 mm. weight 2700-3400 gms. Face and body has a loose wrinkled appearance because of subcutaneous fat deposit. Body is usually lump and lanugo disappears Nails reach fingertip edge Amniotic fluid decreases. Increase Development. Sole of the foot have already creases. Good chance of survival. Length 360 mm.; Weight 3400-3600 gms. Skin is smooth, chest is prominent Eyes are uniformly slate colored Bones of skull are ossified and are nearly together at sutures. Testes are in scrotum. Optimum Time for survival. Full term. Lightening is present.


V. Fetal Circulation
As early as 3rd week of intra-uterine life, fetal blood is already is circulating, specifically there is already exchange of nutrients with the maternal circulation in the chorionic villi. > Arteries carry UNOXYGENATED BLOOD. VEINS carry OXYGENATED BLOOD. > Fetal Circulation Bypass: Why: DUE TO NON-FUNCTIONING LUNGS: ----- Ductus arteriousus (between pulmonary artery & Aorta, OPENS AT BIRTH & CLOSES 24 48 hours after delivery.) It CONTAINS a mixture of arterial & venous blood. ----- Foramen Ovale : between right & left atrium DUE TO NON-FUNCTIONING LIVER: ----- Ductus Venosus (by pass the liver, closes at birth; an umbilical vein that carries High oxygen from the placenta.


Figure I. i Changes in Fetal circulation (Prenatal to Post natal Circulation)

V.a Measuring Age of Gestation


Figure I. J Fundic Height 1. Estimated Date of Confinement (EDC) March 20, 1995 Minus-3 months +7 days +1 year December 27, 1996 2. McDonalds Formula (age of gestation) Fundic ht in cm x 2 divided by 7 = AOG in months 21 cm x2 7 = 24 weeks 3. Fetal Length (Haases Rule) 1 5 months - =months (squared) 6 - 10 months = months x 5

VI. Maternal & Fetal Diagnostic tests

CHORIONIC VILLI SAMPLING Earliest test possible on fetal cells; sample obtained by slender catheter passed through cervix to implantation site. a. Chorionic Villi Sampling: removal of a small piece of Chorionic villi sampling to detect the ff: fetal chromosome, enzyme, DNA & biochemical abnormalities. Performed between the 8th 11th weeks of gestation. Can detect the ff; Genetic Defects: cystic fibrosis, trisomy 21, Tay Sachs, sickle cell anemia,


thallasemia, Duchenne muscular dystrophy & hemophilia. Most common indication: advance maternal age: increases risk of chromosomal damage from aging of oocyte. Great est Advantage over Amniocentesis: PERFORMED DURING THE FIRST TRIMESTER. (16th- 20th week of gestation). . Laboratory results are obtained in 1 - 7 days compared to 20-28 days for an amniocentesis. Disadvantages: 1. Risk of Abortion 2. Infection 3. Embryo-fetal/placental damage 4. Spontaneous abortion 5. Premature rupture of the membranes After an Rh-negative patient undergoes amniocentesis or CVS, the nurse should administer Rh (D) immune globulin (RhoGAM), to prevent Rh sesnsitization, an antigen antibody immunologic reaction that sometimes occurs when an Rh negative mother carries an Rh + fetus. The patient does not require complete bed rest after CVS---SHE SHOULD REFRAIN FROM SEXUAL INTERCOURSE AND PHYSICAL ACTIVITY FOR 48 hours. A small amount of spotting is normal for the 1st 24-48 hours. ULTRASOUND Use of sound and returning echo patterns to identify intrabody structures; useful early in pregnancy to identify gestational sacs; later uses include assessment of fetal viability, growth patterns, anomalies, fluid volume, uterine anomalies and adnexal masses. Use adjunct to amniocentesis; safe for fetus (no ionizing radiation) Ultrasound: done 18-40 weeks for fetal abnormalities,

No known risk

THE BEST TEST FOR ECTOPIC PREGNANCIES - Non-invasive procedure with high frequency sound waves to obtain outline of the fetus, placenta & uterine cavities


and to confirm gestational age & EDD. - NEEDS A FULL BLADDER TO OBTAIN A BETTER IMAGE (drink a full glass every 15 minutes beginning an hour & half the procedure) - COMMON METHOD IN LOCATING THE PRECISE POSITION OF THE FETUS & PLACENTA BEFORE AMNIOCENTESIS. No known risk


Location and aspiration of amniotic fluid for examination; possible after the 14th week when sufficient amounts are present; used to identify chromosomal aberration, sex of fetus, levels of alpha-fetoprotein and other chemicals indicative of neural tube defects and inborn error of metabolism, gestational age, RH factor. I.V. anesthesia isn't given for amniocentesis. The client should be supine during the procedure; afterward, she should be placed on her left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output. b. Amniocentesis: invasive procedure for amniotic fluid analysis, & fetal lung maturity. Procedure: Ultrasound 1st: the rationale: to locate the Placenta. The patient MUST EMPTY THE BLADDER TO REDUCE THE SIZE OF THE BLADDER. Vital signs are assessed every 15 minutes. Typically performed on the 3rd trimester to assess LECITHINSPHINGOMYELIN RATIO IN THE


AMNIOTIC FLUID (this ratio indicates fetal lung maturity), which is commonly delayed in a diabetic client, Cesarean Delivery should not be done, unless the fetal lungs are matured. Position: Supine. PLACE A FOLDED TOWEL ON HER RIGHT BUTTOCKS TO TIP HER SLIGHTLY TO THE LEFT & MOVE THE UTERUS OFF THE VENA CAVA TO PREVENT SUPINE HYPOTENSION SYNDROME. ABDOMINAL PREP IS DONE, then, needle insertion in a 20-22 gauge spinal needle, withdrawing amniotic fluid. NORMAL L/S RATIO (lecithin/sphingomyelin): 2:1 = normal fetal lung maturity ratio Most important factor affecting Amniocentesis: NEEDLE INSERTION-because of the risk of puncture or damage to the placenta, fetus, umbilical cord, bladder & uterine arteries. Disadvantages: Risk for: 1. Maternal hemorrhage 2. Infection 3. Rh immunization 4. abruptio placenta 5. Amniotic fluid embolism CALL THE PHYSICIAN FOR THE FF: Chills, fever, leakage of fluid, decrease fetal movement or uterine contractions. After amniocentesis, the patient is monitored for uterine contractions, fetal heart rate changes and leakage of amniotic fluid from the puncture site. During this period, the patient isnt ambulated. X-RAY Can be used late in pregnancy (after ossification of fetal bones) to confirm position and presentation; not used in early pregnancy to avoid possibility of causing damage to fetus and mother. Maternal serum screens for open neural tube defects. It is a glucoprote in produced by





fetal yolk sac, GI tract and liver. Test done between 16 and 18 weeks gestation. Alpha Fetoprotein: PRINCIPAL SCREENING TEST DOR THE DETECTION OF NEURAL TUBE DEFECTS (spina bifida, hydrocephalus-can be reduced through increase folic acid-0.4 mg/day in the 1st trimester) > Maternal blood sampling between 16-20 weeks. LOW: chromosomal defects (Downs syndrome) HIGH: (greater than 10 mg/dl) Neural tube defects, anencephaly & the absence of ventral abdominal wall, premature delivery, toxemia & fetal distress & Rh immunization. Uses amniotic fluid to ascertain fetal lung maturity through measurement of presence and amounts of the lung surfactants lecithin and sphingomyelin. At 35-36 weeks; ratio is 2:1 indicative of mature levels. Found in amniotic fluid after 35 weeks. In conjunction with the L/S ratio; it contributes to increased reliability of fetal lung maturity testing. Maybe done in laboratory. Phosphatidyl Glycerol (PG): when present in the amniotic fluid, it can be predicted that respiratory distresss will not occur, or RDS will not occur.


Estimates fetal renal maturity and function, uses amniotic fluid. Level-high early in pregnancy; drops after 36 weeks gestation; uses amniotic fluid. The yellow color is the result of fetal anemia and bilirubin. Teach mother to count 2-3 times daily, 3060 minutes each time, should feel 5-6 movements per counting time; mother should notify care giver immediately of abrupt change or no movement. Uses ultrasound to locate umbilical cord. Cord blood aspirated and tested. Used in second and third trimesters. A collection of data on fetal breathing movements, body movements, muscle tone, reactive heart rate and amniotic fluid volume.





A. Non-Stress Test accelerations in heart rate accompany normal fetal movement; non-invasive
Tocodynamometer records fetal movements and Doppler ultrasound measures - Observation of fetal heart rate related to fetal movement. Fetal well-being. Indicated for: assess placental function & oxygenation, fetal well being, evaluates fetal heart rate in response to fetal movement especially for: Maternal Problems such as chronic hypertension, diabetes and Pre-eclampsia, given after the 32nd week. PREPARATION: Patient should eat snacks.

Position: Semi-Fowlers or left lateral positions the mother may ask tom press the button every time
she feels fetal movements; the monitor records a mark at each point of fetal movement. RESULTS: 1. Reactive (normal): indicates a fetal fetus Greater than 15 beats per minute- occur with fetal movement in a 10 or 20 minute period. FAVORABLE RESULTS: - 2 or more FHR accelerations of 15 seconds over a 20 minutes interval and return of FHR to normal baseline. 2. Non-Reactive (Abnormal): No fetal movement occurs or there is short-term fetal heart rate variability (less than 6 beats per minute). The doctor will order an Oxytocin Test AFTER the patient has non-reactive test.



B. Contraction Stress Test (CST) based on the principle that healthy fetus can withstand
decreased oxygen during contraction but compromised fetus cannot. Response of the fetus to induced uterine contractions as an INDICATOR OF UTEROPLACENTAL & FETAL PHYSIOLOGICAL INTEGRITY. PREPARATION: Woman in semi-Fowlers or side-lying position. Monitor for post-test labor onset. TYPES: a. Mammary stimulation Test or Breast Stimulation Exam or Nipple Stimulated CST non-invasive b. Oxytocin Challenge test Indications: ALL PREGNANCIES AFTER 28 WEEKS WITH HIGH RISK CLIENTS. Contraindicated for history of PRE-TERM LABOR. Interpretations: POSITIVE RESULT: Late decelerations with at least 50% of contractions. Potential risks to the fetus, which may necessitate to C-section.


Abnormal and known as Positive window. Abnormal: Positive Window: (+) LATE DECELERATIONS OF FHR with three contractions a 10 minute interval. Indicates Uteroplacental Insufficiency. NEGATIVE RESULTS: No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in 10 minutes period. Normal: Negative Window: (-) LATE DECELERATIONS OF FHR with three contractions a 10m minute interval Normal and known as Negative window

Laboratory Studies
1. Estriol excretion: measures placental functioning through urine test. Collect a 24-hour urine specimen or serum blood levels. High Estriol: Good placental function Low Estriol: Fetal hypoxia Estriol: estrogenic hormone, synthesized by the placenta & adrenal gland of the fetus which secreted by the ovaries

Rh Incompatibility Test:
Purpose: a. to discover presence of antibodies present in Rh-negative mothers blood. > Test will confirm the diagnosis for Hemolytic Disease in the Newborn. Types: 1. Indirect Coombs Test: women who have Rh negative have this test done to determine if they have antibodies to the factor present. Repeated 28 weeks pregnancy. Mothers reveal antibodies as a result of previous transfusion or pregnancy. 2. Direct Coombs test: tests for newborns cord blood- determines presence of maternal antibodies attached to the babys cell. Rh (D) & D negative who hasnt formed antibodies should receive Rhogam at 28 weeks gestation or after 72 hours after delivery. The Betke-Kleihauer test is a test that determines if a greater than usual fetal maternal blood mix occurred. It is also used in Rh incompatibility cases to determine if another dose of Rhogam is needed

Fern Test: determine the presence of Amniotic Fluid leakage. Using a sterile technique, a specimen is obtained from the external os of the cervix & vaginal pool. Position: Dorsal Lithotomy, Instruct the client to cough to cause the fluid to leak from the uterus if the membranes are ruptured. Nitrazine Test: use of nitrazin strip to detect the presence of amniotic fluid. Vaginal Secretions: PH: 4.5- 5.5 Amniotic fluid: PH: 7.2 7.5 (turns the yellow Nitrazine blue gray, blue green Ruptured Membranes) Kicks count: fetal movement counting mother sits quietly on the LEFT SIDE for 1 hour after meals & count fetal kicks for 30 minutes. Notify the physician or health care provider if FEWER THAN 3 KICKS. Biophysical Profile : surveillance of fetal well being base on 5 categories: 1. Fetal breath movt 2. Fetal tone 3. Amniotic fluid


4. Fetal heart reactivity 5. Placental Grade Interpretation: Fetal score of 8 10: normal fetal well-being Fetal score of 4 6: fetal distress

VII. Other Gynecological Procedures

a. Schiller Test: indicated for cancer, candidates are women of 20 years old & above & sexually active women. > Cervix is tainted with tincture of iodine; color change in the cervix is noted. Result: Negative: mahogany brown stain Positive: no staining

b. Papanicolau Test: cytologic test for cancer > Detect precancerous lesions &, detect the recurrence of Cancer. c. Hysterosalphingogram : COMPLETE EVALUATION OF ALL PELVIC ORGANS IN FEMALES > EVALUATES TUBAL PATENCY & PROBLEMS IN FERTILITY. > If the tubes are patent, the dye can be visualized passing out the fimbtriated end & of the fallopian tubes. d. Rubins Test- determines tubal patency of the fallopian tubes. CO2 is passed through the cervix to the uterus. > If patent, gas will pass through the fimbriated end of the fallopian tubes, will give a sensation of fullness & spasmodic pains due to irritation from the gas. > A test to detect infertility caused by a defect in the tube, which is usually related to Past Infection. e. Sims Huhner Test (Post Coital Test): within 1 2 days, a specimen of seminal fluid from the posterior fornix & cervical canal is aspirated 2 4 hours after coitus. Purpose: test for incompatibility of sperms with cervical mucus. 1-2 days is the best time to evaluate fertility because there is increase estrogen. - ABUNDANT CERVICAL MUCUS- increases sperm survival.


PRESUMPTIVE Amenorrhea Nausea/Vomiting Breast sensitivity and increased size Fatigue Abdominal enlargement Skin pigmentation changes (Melasma chloasma, linea nigra- a brown line running from the umbilicus to the symphysis pubis Stretch marks will eventually fade to a silvery white color, PROBABLE Pregnancy test (presence of HCG) Softening of the uterine isthmus (Hegars sign) Cervical softening (Goodells sign) Goodells sign is a softening of the cervix, which occurs in pregnancy POSITIVE Auscultation of fetal heart by week 8 Ultrasound imaging of fetal heart motion by week 7 Ultrasound confirmation of gestational sac by week 6

Ultrasound: 6 weeks can Palpating fetal contours auscultate the fetal heart. Braxton-Hicks contractions Ballotment: bouncing of the fetus in theFetal movements palpated by amniotic fluid against the examiners hand. During the 16 provider by week 20. the Braxto


but it is highly unlikely that they will completely disappear. Breast changes- increase in fullness, darker areola. *Quickening: first fetal movt. *Urinary Frequency * Melasma .

n Hicks Contractions: painless contractions felt for 20-30 minutes occurs on the 16th week. Chadwicks sign is a bluish coloring of the vaginal mucosal that occurs as early as 6 weeks gestation. Rationale: due to increase vascularity & blood vessel engorgement. Increase size of the uterus * + Pregnancy Test > Secretion of HCG in the urine (Frog Test). Detectable 10 days after the missed period . The fetal heartbeat typically can be heard and fetal rebound is possible between 18 and 22 weeks. The fetal outline becomes palpable and the fetus is highly mobile between 28 and 31 weeks. Braxton Hicks contractions increase in frequency and intensity between 32 and 35 weeks.

The most objective sign of pregnancy is fetal movement felt by the examiner.

IX. Discomforts in Pregnancy

Discomfort Nausea & Vomiting Urinary Frequency Breast tenderness & Engorgement Heartburn Trimester ends on the 1st trimester ends on the 1st trimester May start on the 3rd trimester also all trimester phases 2nd - 3rd Nursing Measure > dry crackers & eat small frequent feedings Kegels exercise, > wear supportive well fitting bra > avoid soap: to prevent drying > smaller meals, shorter intervals > Avoid fatty foods & Na Bicarbonate > Drink milk between meals > Increase water (8-12 glasses) - to minimize regurgitation > leg extension & feet dorsiflexion relief- nursing intervention > Elevate the legs with a pillow (Prevention)

Muscle & Leg cramps



Varicosities Bach aches Supine Hypotensive Syndrome Leukorrhea Fatigue

3rd 3rd 3rd 3rd 2nd

Wear supportive hose. NOT KNEE HIGH HOSE > Wear low heeled shoes. Sitting & Pelvic Rocking > Left Lateral side lying position: relieve inferior vena cava syndrome > Avoid Douche. Hygiene. > due to Iron Deficiency Anemia The diagnosis of iron-deficiency anemia is made on the basis of a hemoglobin concentration value of 10 g/dl blood or less and a hematocrit value of 30% or less. Frequent rest periods & give dark leafy vegetables



Prevention: High fiber Intervention: Increase Fluid NOTE: Bulk and fluid help increase peristalsis. Laxatives and suppositories should not be used routinely in pregnancy. Prevention is more desirable than treatment.




First The benefits of drug therapy outweigh the risks to the patients nausea is to control in a first trimester patients nausea. Second The second trimester of pregnancy, women generally feels their best.

Ambivalence Fear Fantasies about motherhood and about having a dream child. Possible decrease in sex drive. Alternate feelings of emotional well-being and liability. Acceptance of pregnancy. Possible increase in sex. Adjustment to change in body image.

Accepting the pregnancy I AM PREGNANT During the first trimester, the mother copes with the common discomforts and changes Accepting the baby A BABY IS GROWING INSIDE ME . During the second trimester, psychosocial tasks include mother-image development, coping with body image and sexuality changes, and prenatal bonding. Preparing for parenthood. I AM A MOTHER During the third trimester, a key psychosocial task is to overcome fears the woman may have about the unknown, labor pain, loss of self-esteem, loss of control, and death. The emotions and fears that are usually felt during the third trimester are feelings of ugliness, alterations in body self-image and anxiety about the coming labor and delivery.


Feelings of awkwardness and clumsiness. Renewed fears and tensions about labor. Spurt of energy during last month. .

A. MATERNAL ADAPTATIONS DURING PREGNANCY / with BIOLOGICAL TASKS OF PREGNANCY First Trimester: AMBIVALENCE- about pregnancy: pregnant woman focus only to self. I am pregnant. Accept the biological fact of pregnancy Second Trimester: ACCEPTANCE---of the identification of motherhood & awareness & interest in the fetus. I am going to have a baby Accept the growing fetus as distinct from self & as person to care for Third Trimester: EMOTIONAL LABILITY- assuming already the mother, fears & fantasies & dreams about labor I am going to be a motherPrepare realistically for birth & parenting B. PATERNAL ADAPATATIONS / REACTIONS TO PREGNANCY COUVADE SYNDROME: identification of the mother; ambivalence & anxiety about the role change JEALOUSY STAGE: increase interest in mothers care. SELF-CONCEPT CHANGE: active involvement in the fears & death of the fetus.



A. Abortion

of pregnancy before the fetus is viable (20 weeks or a weight of 500 g)










Fig. 4.4 T y p e s o f A b o r t i o n TYPES 1. Threatened DEFINITION The continuation of the pregnancy is in doubt S/S Bleeding or spotting closed cervix NURSING INTERVENTION Bedrest, Restrictive activity, Sedation, Avoid coitus for 2 weeks following last evidence of bleeding Rhogam indicated when a young patient has a threatened abortion in the first trimester and a laboratory studies reveal an Rh negative and the husband is Rh positive Save tissue fragments Continuous monitoring Dilatation & Curettage; Use of oxytocin: Oxytocin nasal spray should be administered while the client is sitting with her head in a vertical position. A nasal preparation must not be administered with the client lying down or the head tilted back because this could cause aspiration. Evacuation Evacuation, D & C

2. Inevitable 3. Complete 4. Incomplete

Threatened loss that can be prevented; abortive process is going on Products of conception are totally expelled Some fragments are retained inside the uterine cavity

Bleeding and cervical dilation Minimal bleeding Profuse bleeding

5. Missed

Retention of the products of conception after fetal death

Intermittent bleeding; absence of uterine growth


6.Habitual / Recurrent

3 spontaneous abortions occurring successively

Provide IV, Monitor bleeding, Count perineal pads, psychological support NOTE:Because spontaneous abortion is threatening, all perineal pads must be inspected for the products of conception. Fluid replacement is necessary because of blood loss

B. Ectopic Pregnancy A. Description: A pregnancy that occurs in another than uterine site, with implantation usually occurring in fallopian tubes

A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Causes -Narrowing of tube -Pelvic infection -Endometriosis -Smoking -History of IUD usage . Signs and Symptoms -Vaginal Bleeding -Knife-like abdominal pain -Referred pain on the right shoulder -Symptoms of Shock: decreased BP increased RR, fast but thready pulse. This is the number 1 complication. -Pelvic pressure of pelvic fullness -Cullens sign -Pain unilaterally, with cramping and tenderness - Mass in the adnexal or cul-desac - Slight, dark vaginal bleeding - Profound shock if rupture occurs Diagnostic Tests -Culdocentesis -Culdoscopy -Radioimmunoassay of elevated serum qualitative -Beta-HCG -Abdominal Ultrasound -Blood samples of Hgb and Hct; blood type and group Management Monitor amount of bleeding Assess vital signs Assess abdominal pain Blood transfusion Surgery: Salpingostomy Administer Rhogam for Rh (-) client


The #1 Complication of Ectopic Pregnancy is Hemorrhagic Shock.

C. Hydatidiform mole / Trophoblastic Disease / Molar Disease

Gestational trophoblastic neoplasm that arise from the chorion; characterized by the proliferation and degeneration of the chorionic or trophoblastic villi.

A patient with Hydatidiform mole has a positive signs of pregnancy but is not pregnant. The #1 Complication is Choriocarcinoma The Three H of H-mole 1.Hyper - emesis gravidarum 2. increase Hcg 3. increase incidence for piH

PREDISPOSING FACTORS 1. Low socioeconomic status 2. Women below 18 or above 35 3. Intake of Clomid (Clomiphene Citrate) 4. Women of asian heritage

TYPES 1. Complete/ classical parts of the villi are affected 2. Incomplete/ partial- some parts are normal

MANIFESTATIONS 1. Vaginal bleeding 2. Excessive N/V 3. Rapid enlargement of the uterus 4. (+) Pregnancy test 5. Possible PIH 6. Abdominal cramps 7. Absent FHR 8. Elevated HCG titer: 1-2 million IU; Normal level: 400,000 IU

DIAGNOSTIC TESTS 1. HCG titer determination 2. Ultrasound 3. X-ray of the abdomen

MANAGEMENT 1. Molar evacuation / D&C 2. Chemotherapy 3. Monitor HCG levels 4. Delay childbearing plans for a year 5. Perineal pad counts 6. Instruct the couple to have VAGINAL REST ( no sex) for 1 year.

The #1 Complication of H-mole is choriocarcinoma


D. Incompetent cervix - Painless premature dilatation of the cervix (usually in the 16th to 20th week)


Figure 19

Synonyms Predisposing/Contributing Factors: Dysfunctional cervix 1. Repeated dilatation of the cervix, maternal DES ( Diethylstilbestrol) Exposure, Traumatic injuries to the cervix. Congenital anomaly 2. Trauma to the cervix (surgery / birth) 3. Uterine anomaly 4. Habitual abortion 5. Pre-term labor 6. Show (a pink-stained vaginal discharge) 7. #1 Sign: Rupture of membranes and discharge of amniotic fluid 8. Pressure or heaviness on the lower abdomen.

Initial Signs

Late signs: Cardinal/Pathognomonic/major sign:

1. The cervix dilates painlessly in the second

trimester of pregnancy. Bloody show 2.PROM 3.Painless dilatation 9. Birth of dead/non-viable fetus 10.Ultrasound 11.Ultrasonography 12.Cervical Cerclage, McDonald Cerclage 13.Sterility, rupture of the cervix premature delivery, pelvic bleeding and infection. #1 Hemorrhage, Ectopic pregnancy, birth defects, viruses and pregnancy diseases, diabetes in pregnancy, HPN Side lying position Prone position Suction Cervical Incompetence Pre-op: Encourage patient to maintain bed rest Post-op: Check for excessive vaginal discharge and

Screening or initial diagnostic test: Conformity test: Best major surgery: Possible surgical complication: Disease complication

Best position before and after surgery Best side equipment Nursing Diagnosis Nursing Intervention


severe pain. 1. Bed rest in trendelenburg position 2. Administer tocolytic medications as ordered Eg; Ritodrine Hydrochloride (Yutopar): Terbutaline sulfate (Brethine): Magnesium Sulfate Hydroxyzine hydrochloride (Vistaril) is a common drug ordered to counteract the effect of terbutaline (Brethine) 3. Surgery: Cervical Cerclage a. Shirodkar-Barter Technique ( internal os) permanent suture: subsequent delivery by C/S. b. Mc Donald Procedure ( external os)-suture removed at term with vaginal delivery Usually 4-6 weeks after vaginal delivery is the safe period for a patient to resume sexual activity, when the episiotomy has healed and the lochia had stopped - Monitor V/S and report HPN Monitor FHR Limit activities Observe for Ruptured BOW Avoid vaginal douche Avoid coitus (Pillitteri, Maternal and Child Nursing, p.391-93) E. DIABETES MELLITUS Gestational diabetes mellitus (pregnancy induced) A pregnant, insulin-dependent diabetic is at risk for sudden hypoglycemia because insulin needs and metabolism are affected b pregnancy, making sudden hypoglycemic episodes more common for diabetics. Changes in the glucose-insulin mechanism: o Early in pregnancy: A. Increase production of insulin B. Maternal glucose is consumed by fetus o Late in pregnancy: A. Mother develops insulin resistance B. The presence of placental insulinase breaks down insulin rapidly B. Description of Diabetes in Pregnancy 1. 2. 3. Maternal glucose crosses the placenta but insulin does not During the first trimester, maternal insulin needs decrease The fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions



During the second and third trimesters, increases in placental hormones cause an insulin-resistant state, requiring an increase in the client's insulin dose trimester. Premature delivery is more frequent. The newborn infant of a diabetic mother may be large in size but will have functions related to gestational age rather than size. The newborn infant of a diabetic mother is subject to hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, and congenital anomalies. Stillborn and neonatal mortality rates are higher in pregnancies of a diabetic woman

5. Diabetes mellitus is more difficult to control during pregnancy & occurs during the second or third

NOTE: The greatest incidence of insulin coma during pregnancy occurs during the second and the third months, the incidence of the diabetic coma during pregnancy occurs around the sixth months.



A type of Diabetes where only pregnant women

gets where her blood sugar rate elevates but never had a high blood sugar rate before pregnancy. 15. Diabetes during Pregnancy 16. Hyperglycemia develops during pregnancy because of the secretion of placenta hormones such as Prolactin, Progesterone& Corticosteroids Maternal age more than 35 Previous macrosomic infant Previous unexplained stillbirth Previous pregnancy with GDM Family history of DM Obesity Hypertension 17. FBS more than 140 mg/dl 18. 3-Ps: Polyuria, Polydipsia and Polyphagia MATERNAL SIGNS & SYMPTOMS: 1.Excessive thirst 2. Hunger 3. Weightless 4. Blurred vision 5. Frequent urination 6. Recurrent urinary tract infections and vaginal yeast infections 7. Glycosuria and ketonuria 8. Signs of pregnancy-induced hypertension 9. Polyhydramnios 10. Fetus large for gestational age 19. Fatigue, weakness, sudden vision changes, tingling or numbness in hands 20. Weight loss, fatigue, nausea, and vomiting excessive thirst, decrease urination 21. 50 gms oral glucose challenge test 22. 3- hour glucose tolerance test will be performed to confirm diabetes mellitus

Synonyms Predisposing/Contributing Factors

Initial Signs

Late signs Cardinal/Pathognomenic/major sign Screening or initial diagnostic test Confirmative test


Best diet

23.Glycosolated Hemoglobin less than 8% 23. Strict Diabetic Diet 24. . Calories in diet should consist of 50% to 60% carbohydrates, 12% to 20% protein, and 20% to 30% fat NOTE: Because insulin does not pass into the breast milk, breastfeeding is not contraindicated for the mother with diabetes. Breastfeeding is encouraged; it decreases the insulin requirements for insulin-independent clients. Breastfeeding does not increase the risk of maternal infection; it leads to an increased caloric demand. Infants of diabetic mothers often display jitteriness in response to hypoglycemia after birth 25. Well-balanced Caloric Diet 26. Maternal Complications: PIH, Placental disorders, stillbirth, macrosomia, neural tube defects. 27. Fetal Diabetic Complications: Macrosomia Pre-eclampsia Hydramnios Congenital anomalies NOTE: The incidence of congenital anomalies among infants of diabetic pregnancies is three to four times higher than that in general population and is related to the high maternal glucose levels during the third to sixth gestational weeks.

Best diet for the disease: Disease complication

Best side equipment

Best drug Nature of the drug Nursing Diagnosis

Nursing Intervention

Glucometer Insulin Equipment #1 Eternal Electronic Fetal Heart Rate monitoring Insulin therapy ( dont use Oral hypoglycemics, they are Teratogenic) Insulin #1 High Risk for fluid volume deficit related to polyuria and dehydration Imbalanced nutrition related to imbalanced of insulin, food and physical activity Potential heath care deficit related to physical improvements or social factors.. MANAGEMENT 1. Screen clients between the 24th and 28th weeks of pregnancy 2. Prenatal visits bimonthly for 6 months and weekly thereafter. 3. Calories in diet should consist of 50% to 60% carbohydrates, 12% to 20% protein,


and 20% to 30% fat 4. Observe client closely for an insulin since a precipitous drop in insulin required is usual 5. Monitor for signs of infection or post hemorrhage 6. If a pregnant diabetic is in labor, her blood glucose should be monitored hourly. The preferred method of administration if insulin is required during labor is intravenous OTHER IMPORTANT MANAGEMENT: Urine testing Blood glucose determination Insulin administration Dietary management Exercise Fetal surveillance: (* Non-stress test * contraction stress test * amniocentesis)

(Pillitteri, Maternal and Child Nursing, p.349-356)


CLASSIFICATION Class I Asymptomatic Class II Asymptomatic at rest; symptomatic with heavy physical activity Class III Asymptomatic at rest; symptomatic with ordinary activity Class IV Symptomatic with all activity; symptomatic at rest

EFFECTS Retarded growth Fetal distress To relieve fetal distress let the patient lie on her side Premature labor You dont have to notify the physician if the patient complains of a fluttering sensation in her chest because of taking terbutaline (Brethine) SQ for premature contractions because it is a common side effect unless vital signs indicate stress

a. Class I: no limitation of activities. No symptoms of cardiac insufficiency. b. Class II: slight limitation of activity, Asymptomatic at rest. Ordinary activities causes fatigue, palpitations and dyspnea c. Class II: marked limitation of activities, comfortable at rest, less than ordinary activities causes discomforts d. Class IV: unable to perform any physical activity without discomfort. May have the symptoms during rest.

MANAGEMENT Goal is to reduce workload of heart Promote rest Promote a healthy diet Educate regarding medication Educate regarding avoidance of infection Promote reduction of physiologic stress



DISEASE Synonym Predisposing / Contributing factors MILD SEVERE (PREGNANCY-INDUCED HYPERTENSION) -Primiparas younger than age 20 years or older than 40 years; women from low socioeconomic background because of poor nutrition; women of color; women with heart disease, diabetes with vessel or renal involvement, and essential hypertension; poor calcium and magnesium intake (Pillitteri, A. 1999 p. 393) hydatidiform mole; multiple gestation, polyhydramnios, preexisting vascular disease (The Lippincott Manual of Nursing Practice, 7 th ed., 2001.p.1190) -Age-related concern: adolescents and primiparas over age 35 are at higher risk for preeclampsia.( Nurses 3 minutes clinical page 442 -443 Author: Gloria F Donnelly M.Phd B140/90 mmGh on at least two occasion 6 hours apart (The Lippincott Manual of Nursing Practice 7th ed.,2001.p.1190) proteinuria of 1-2+ on a random sample; weight gain over 2 lbs per week in second trimester and 1 lb per wk, third trimester; mild edema in upper extremities or face (Pillitteri, a., 1999.p.395) BP160/110 mmHg or diastolic pressure110 mmHg on two occasions at least 6 hours apart with the patient on bedrest; proteinuria 5 b/24 h or 3+ to 4+ on qualitative assessment (urine dipstick) (The Lippincott Manual of nursing Practice 7th ed.2001.p.1190) extreme edema in hands and face/puffiness (Pillitteri,A.,1999.p.396) Oligauria 400 to 500 ml/24h; cerebral or visual disturbances (altered level of consciousness, headache, scotomata, or blurred vision); epigastric pain or RUQ pain, pulmonary edema or cyanosis; impaired liver function of unclear etiology; thrombocytopenia (platelet count <150,000); development of eclampsia (The Lippincott Manual of Nursing Practice, 7th ed.2001.p.1190) elevated serum creatinine > 1.2 mg/dl; Signs and symptoms of severe pre-eclampsia, p.395; temperature rises sharply to 39.4C or 40C (103F to 104F) from increased cerebral edema; reflexes become hyperactive p.399, premonition that something is happening; epigastric pain and nausea; urinary output less than 30 ml/h p.400 (Pillitteri, A., 1999) During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences.

Initial Sign

Late Sign

Signs of Worsening PIH or Impending Seizures BP 160/110 mm Hg or above Epigastric pain Decreased urinary output Visual changes Headache


cardiac involvement; extensive perkipheral edema (Pillitteri, a., 1999.p.395) Cardinal / Pathognomonic/ Major Sign Nursing Diagnosis and Nursing Interventions Hypertension and proteinuria are the most significant. Edema is significant only if hypertension and proteinuria or signs of multi-organ system involvement are present. (Pillitteri, A., 1999.p.394) Fluid volume excess related to pathophysiologic changes of PIH and increased risk of fluid overload. Maintaining Fluid Balance 1. Control IV intake using a continuous infusion pump. 2. Monitor input and output strictly; notify health care provider if urine output is <30 ml/h. 3. Monitor hematocrit levels to evaluate intravascular fluid status. 4. Monitor vital signs every hour. 5. Auscultate breath sounds every 2 hours, and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate). Promoting Adequate Tissue Perfusion 1. Position on side, preferably the left side to promote placental perfusion. 2. Monitor fetal activity. 3. Evaluate NST to determine fetal status. 4. Increase protein intake to replace protein lost through kidneys. Preventing Injury 1. Instruct on the importance of reporting headaches, visual changes, dizziness, and epigastric pain. 2. Instruct to lie down on left side if symptoms are present. 3. Keep the environment quiet and as calm as possible. 4. If patient is hospitalized, side rails should be padded and remain up to prevent injury if seizure occurs. NOTE: The patient with a diagnosis of PIH should be close to the nurses station because she requires close observation. The patient also should be placed in a room with decreased stimuli. Maintaining Cardiac Output 1. Monitor IV intake using a continuous infusion pump. 2. Monitor input and output strictly; notify primary care provider if urine output is < 30 ml/h. 3. Monitor maternal vital signs; especially mean

Altered tissue perfusion, Fetal cardiac and cereral, related to altered placental blood flow caused by vasospasm and thombosis. Risk for injury related to convulsions. Decreased cardiac output related to decreased preload or antihypertensive therapy.


blood pressure and respirations.

4. Assess edema status, and report pitting edema

5. of + 2 to primary care provider. Monitor oxygenation saturation levels with pulse oximetry. Report oxygenation saturation rate of <90% to primary care provider.

(The Lippincott Manual of Nursing Practice, 7th ed., 2001.pp.1192-1193) Screening/Initial diagnostic test Confirmatory Test Blood pressure over 140/90, or increase of 30 mm systolic, 15 mm diastolic over pre-pregnancy level. (Pillitteri, A. 1999.p.395) 24-hour urine for protein of 300 mg or greater; elevated serum BUN and creatinine; increased deep tendon reflexes and clonus; blood pressure changes meeting criteria for diagnosis (The Lippincott Manual of Nursing Practice,7th ed., 2001.p.1190) The woman needs a moderate to high-protein, moderate-sodium diet to compensate for the protein she is losing. (Pillitterri, A., 1999.p.398)

Best Diet Disease Complications

Abruptio placentae (Hypertension in PIH leads to vasopasm. This in turn

causes the placenta to tear away from the uterine wall (abrupto placentae) (Mosbys Comprehensive Revew of Nursing for NCLEX- RN p. 226) disseminated intravascular coagulation; HELLP syndrome; prematurity; intrauterine growth restriction (IUGR) from decreased placental perfusion; maternal/fetal death; hypertensive crisis; acute renal failure; hemorrhage; cerebrovascular accident; blindness; hypoglycemia; hepatic rupture (The Lippincott Manual of Nursing Practice,7th ed., 2001.pp.1192) SEVERE PRECLAMPSIA: Lateral recumbent position (Pillitteri,A.,1999.p.397) ECLAMPSIA: to prevent aspiration, turn the woman on her side to allow secretions to drain from her mouth. (Pillitteri,A.,1999.p.400) Infusion pump; pulse oximeter (The Lippincott Manual of Nursing Practice,7th ed.,2001.pp.1192-1193) Mgnesium sulfate: 4-6 loading dose of 50% give IV over 15-30 mins followed by a maintenance dose (secondary infusion) of 1-4 g/h or IM injection or 10 g (5 g in each buttock) as a loading dose followed by 5 g every 4 hours (The Lippincott Manual of Nursing Practice,7th ed., 2001.pp.1190)s Administer antihypertensives such as hydralazine (Apresoline) as prescribed, to prevent a cerebrovascular accident Best tocolytic agent; antihypertensive; anticonvulsant/eclampsia #1 Complication of MgSO4 is : Respiratory Depression

Best Position

Beside Equipment Best Drug


Reflexes, respiration and urinary output are priority assessments during administration of magnesium sulfate therapy in patients with PIH. If the patients magnesium levels increase above the therapeutic range (4 to 8 mg/dl), the absence of reflexes is often the first indication of toxicity. Reflexes often disappear at serum magnesium levels of 8 to 10 mg/dl. Respiratory depression occurs at levels of 10 to 15 mg/dl, and cardiac conduction problems occur at levels of 15 mg/dl and higher. Urinary output of less than 30ml/hour may result in the accumulation of toxic levels of magnesium.


Pillitteri, A. 1999. Maternal and Child Health Nursing, Care of the Childbearing


& Chidlrearing Family, 3rd ed. Lippincott Williams & Wilkins: Philadelphia, USA. The Lippincott Manual of Nursing Practice, 7th ed., 2001.Lippincott Williams & Wilkins: Philadelphia, USA. Proper Assessment of Abnormal Reflexes Assessment Patellar Reflexes Position the client with legs dangling over the edge of the examining table or lying on back with legs slightly. Strike the patellar tendon just below the kneecap with the percussion hammer. Normal Response: Flexion of the arm at the elbow. Clonus Position the client with legs dangling over the edge of the examining table. Support the leg with one hand and sharply dorsiflex the clients foot with the other hand. Maintain the dorsiflexed position for a few seconds; then release the foot. Normal Response: (Negative Clonus Response) Foot will remain steady in the dorsiflexed position. No rhythmic oscillation of jerking of the foot will be felt. When released, the foot will drop to a plantar flexed position with no oscillations. Abnormal Response: (Positive Clonus Response) Rhythmic oscillations when the foot is dorsiflexed. Similar oscillations will be noted when the foot drops to the plantar flexed position.

G. BLEEDING DISORDERS AFFECTING THE PLACENTA Placenta: contains 20 cotyledons, weighs 400-600 grams. Develops on the 3 rd month. Form from Chorionic villi & deciduas basalis. Deciduas (meaning endometrial changes & growth) Functions: Main source of nourishment & acts a transfer organ for metabolic purposes for the fetus. Placental Problem Placental separation is characterized by a sudden gush or trickle of blood from the vagina, further protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. With cervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartum hemorrhage, usually caused by uterine atony, the uterus isn't globular. Uterine involution can't begin until the placenta has been delivered.

Placenta Previa (low implantation) Assessment:

Abruptio Placenta (Premature separation) Assessment:


. . . . .

Painless Heavy bleeding Soft, non tender, relaxed uterus w/ normal tone Shock in proportion to observed blood loss Signs of fetal distress usually not present

Predisposing Factors: * Multiparity* Advancing maternal age, * Multiple gestation* Alteration in the uterine structures Nursing Considerations: . Client is hospitalized and put on bed rest . Continually monitor fetal well- being . Caesarean delivery indicate . Measure blood loss through perineal pad counts . NO vaginal exams . Provide emotional support

. Severely painful . Heavy bleeding w/c maybe partially\completely hidden . Rigid (board like), tender uterus possible w/ contractions . Shock seeming to be out of proportion . Signs of fetal distress Predisposing Factors: * Chronic Hypertensive disease* history of a short cord * Multigravida * trauma Nursing Considerations: . Bed rest in wedge position too prevent supine hypotension . . . . . Continually monitor fetal well- being Treat signs of shock and hemorrhage Provide emotional support Prepare for delivery


Figure 20 a PLACENTA PREVIA > Improperly implanted placenta in the lower uterine segment near or over the internal cervical os > Total: the internal os is entirely covered by the placenta when cervix is fully dilated > Marginal: only an edge of the placenta extends to the internal os > Low-lying placenta: implanted in the lower uterine segment but does not reach the os (Saunders page 299) > Maternal age > Parity (no. Of pregnancy)


Predisposing Factor


> Previous uterine surgery Cardinal Manifestation > > > > > > Painless bleeding as early as 7 months (mild to hemorrhage) Soft uterus Abdominal fetal position of breech or transverse lie Uterine contractions Anemic anemia, #1hemorrhage, #2shock, renal failure, #3 disseminated intravascular coagulation, cerebral ischemia, maternal and fetal death (Nursing Alert p.418) > Ultrasonography to confirm the pressure of placenta previa. > Depends on location of placenta, amount of bleeding and status of the fetus. > Home monitoring with repeated ultrasounds may be possible with type Ilow lying > Control bleeding > Replace blood loss if excessive > Cesarean birth if necessary > Betamethasone is indicated to increase fetal lung maturity. (Mosby, Comprehensive p. 203) #1 NURSING DIAGNOSIS: Potential fluid volume deficit > Maintain bed rest > #1 Assessment - Monitor maternal vital signs, FHR, and fetal activity > Assess bleeding (amount and quality) > Monitor and treat signs of shock > Avoid vaginal examination if bleeding is occurring > Prepare for premature birth or cesarean section > Administer IV fluids as ordered > Administer iron supplements or blood transfusion as ordered (maintain hematocrit level) > Prepare to administer Rh immune globulin The patient with placenta previa should be maintained on bed rest, preferably in a side-lying position. Additional pressure from an upright position may cause further tearing of the placenta from the uterine lining. Ambulating would therefore be indicated for this patient. Performing a vaginal examination and applying internal scalp electrode could also cause the placenta to be further torn from the uterine lining. > Ultrasound for placenta localization NOTE: Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the third trimester unit a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus who is at risk for severe hypoxia. (Saunders Comprehensive 2002 Edition, p. 304) > Left lateral position ABRUPTIO PLACENTAE

Complication Therapeutic Interventions

Nursing Diagnosis with Nursing Intervention


Confirmatory Test

Best Position


Figure 21


Synonyms Predisposing Factor

ABRUPTIO PLACENTAE Premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered (Saunders page 299300) > Placental abruption > Premature separation of placenta > Maternal age > Parity > Previous abruptio placentae, multifetal gestation


> Hypertension NOTE: Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking and alcohol or cocaine abuse. It is also associated with physical and mechanical factors such as over distension of the uterus that occurs with multiple gestation or polyhydranions. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors. (Saunders Comprehensive 2002 Edition, p. 305) > Spontaneous rupture of blood vessels at the placental bed may due to lack of resiliency or to abnormal changes in uterine vasculature. > May be complicated by hypertension or by an enlarged uterus that cant contract sufficiently to seal off the torn vessels > Consequently, bleeding continues unchecked, possibly shearing off the placenta partially or completely. (Nursing Alert p.4) > Painful vaginal bleeding > Hypertonic to tetanic, enlarged uterus > Board-like rigidity of abdomen (Cullen Sign) > Abnormal/absent fetal heart tones > Pallor > Cool, moist skin > Bloody amniotic fluid > Rising fundal height from blood trapped behind the placenta > Signs of shock > Manifestation of coagulopathy NOTE: Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike upon palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding. (Saunders Comprehensive 2002 Edition, p. 304) > Hemorrhage, shock, renal failure, disseminated intravascular coagulation, maternal death, fetal death(Nursing Alert p.4) > Replacement of blood loss. > With moderate or severe separation or maternal or fetal distress: emergency childbirth. NOTE: The goal of management in abruption placentae is to control the hemorrhage and




Therapeutic Interventions


Nursing Diagnosis with Intervention

deliver the fetus as soon as possible. Delivery is the treatment of choic if the fetus is at term gestation or if the bleeding is moderate to severe and mother or fetus is in jeopardy. (Saunders Comprehensive 2002 Edition, p. 304) > With mild separation without fetal distress and in the presence of some cervical effacement and dilatation: induction of labor may be attempted >Oxygen if necessary > Maintenance of fluid and electrolytes balance. (Mosby, Comprehensive p. 204) #1 NURSING DIAGNOSIS: Risk for fluid volume deficit > #1 Assessment: Monitor and FHR > Assess for vaginal bleeding, abdominal pain, and increase in fundal height > Maintain bed rest > Administer oxygen as prescribed > Monitor and report any uterine activity > Administer IV fluid as prescribed > Monitor I & O > Administer blood products as prescribed > Monitor blood studies > Prepare for the delivery of the fetus as quickly as possible > Monitor for signs of disseminated intravascular coagulation in the post-partum period > Ultrasound detects retro-placental bleeding VENA CAVA SYNDROME

Confirmatory Test

Definition Synonym Predisposing factors

The venous return to the heart is impaired by the weight of uterus. Supine Hypotensive Syndrome Thrombophlebitis NOTE: Contribute to clot formation motion include inactivity,reduced cordiac output, compression of the viens in pelvis or legs The most likely cause of supine hypotension is feeling dizzy, short of breath and clammy when lying back for long periods of time in patients 6th month of pregnancy. The cause of supine hypotension during pregnancy is the weight of the uterus compresses the inferior vena cava, decreasing the return of blood to the heart, thus decreasing cardiac output, which lowers the blood pressure Fatique, proxymal nocturnal dyspnea, orthopnea, hypoxia, cyanosis Reduce renal perfection, Decrease glomerular filtration

Initial sign Late Sign


Cardinal sign

Initial / Screening test

Confirmatory test

Nursing Diagnosis

Nursing Intervention

Best major Surgery Best dirt for pre-operative Best diet for Disease Possible Surgical Complication Complication of Disease

Best position pre-operative

Bed Side Equipment

shock such as tachycardia NOTE: Caused by reduced cardiac output, respiratory distress, fatal distress FHT monitor NOTE: Above 160 or below 120 beats per minutes, Fetal PH below 7.5 Amniotomy: NOTE: Above keeping the significant other improved of the progress of care, the fatal status would he the priority Altered tissue perfection related to decrease blood circulation Risk for altered Health maintenance related to insufficient knowledge of treatments, drug therapies, home care management and prevention of future infection Altered comfort related to maladaptive coping Closely monitor for shock and decreasing blood. Pressure, tachycardia, coal, clammy Skin Maintain patient on bed rest to reduce Oxygen demands and risk for bleeding. Monitor prescribed medication given to preserve right Ventricular felling pressure and increase blood pressure Instruct patient in self care activities Provide information about anti smoking strategies and allow patient time to return demonstration of treatment to the done at home Assess physical complaints matters of facts without emphasizing concern. Use deep breathing, muscle relaxation, and imagery to relieve discomfort. Express a caring attitude Caesarian Section note if cervix is incomplete deleted. Food and fluid are withheld before invasive procedure is not resumed until the client is stable and free of nausea & vomiting. Hypoallergenic Ionic diet Calcium increased Interruption of vena cava, which reduce channel size. > Bleeding as a result of treatment NOTE: Observation of the fetal monitoring often reveal increase uterine rustling tone, caused by failure of the uterus to relax in an attempt to constrict blood vesicle and control bleeding > Respiratory failure. Sims Position NOTE: Turning to the left side to shift right of the fetus off the inferior vena cava. Oxygen obtain equipment for external electronic fetal heart rate monitoring Oxygen with Cannula


History of Disease

Angina, myocardial infarction

Name of the Disease Predisposing / Contributing Factors

Disseminated Intravascular coagulation

Overwhelming infections particularly bacterial sepsis; #1 abruption placenta; eclampsia; amniotic fluid embolism; IUFD(Intra-uterine fetal death) or retention of dead fetus; burn; trauma; fractures; major surgery; fat embolism; sock; hemolytic transfusion reaction; malignancies particularly of lung, colon, stomach, and pancreas NOTE: Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. Platelet are decreased because they are consumed by the process, coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, oozing from injection sites, and presence of hematuria are signs associated with the presence of DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrompophlebitis. (Saunders Comprehensive 2002 Edition, p. 304) Coolness and mottling of extremities; pain; dyspnea; abnormal bleeding Altered mental status; acute renal failure Minimizing Bleeding Risk for injury related to 1. Institute Bleeding precautions bleeding due to 2. Monitor pad count/amount of saturation thrombocytopenia during menses; administer or teach selfadministration of hormones to suppress menstruation as prescribed. 3. Administer blood products as ordered. Monitor for signs and symptoms of allergic reactions, anaphylaxis, and volume overload. 4. Avoid dislodging costs. Apply pressure to sites of bleeding for at least 20 mins, use topical hemostatic agents. Use tape cautiously. 5. Maintain bed rest during bleeding episode. 6. If internal bleeding is suspected, assess bowel sounds and abdominal girth. 7. Evaluate fluid status and bleeding by frequent measurement fo vital signs, central venous pressure, intake and output. Altered tissue perfusion (all tissues) related to ischemia due to microthrombi formation Promoting Tissue Perfusion 1. Keep patient warm 2. Avoid vasoconstrictive agents (systemic or topical). 3. Change patients position frequently and perform ROM exercises. 4. Monitor electrocardiogram and laboratory test for dysfunction of vital organs casued by ischemia arrhythmias, abnormal arterial

Initial Sign Late Sign Nursing Diagnosis & Intervention


blood gases, increased blood urea nitrogen and creatinine. 5. Monitor for signs of vascular occlusion and report immediately. a. Brain decreased level of consciousness, sensory and motor deficits, seizures, coma. b. Eyes Visual deficits. c. Bone Pain d. Pulmonary vasculature chest pain, shortness of breath, tachycardia. e. Extremities cold, mottling, numbness. f. Coronary arteries chest pain, arrhythmias. g. Bowel pain, tenderness, decreased bowel sounds.

Screening or Initial Diagnostic Test Confirmative Test Beside Equipment Best Drug Nature of the Drug References

PT; PTT; Platelet count (Smeltzer, S.C. & Bare, B.G., 1992.p.811) Decreased Fibrinogen level; increased fibrin split products; decreased antithrombin III level ECG; CVP Heparin inhibits clotting components of DIC Anticoagulant Smeltzer,S.C.& Bare, B.G. 1992. Brunner and Suddarths Texbook of MedicalSurgical Nursing, 7th ed. J.B. Lippincott company: Philadelphia, USA. The Lippincott Manual of Nursing Practice, 7th ed., 2001. Lippincott Williams & wilkins: Philadelphia, USA. Pp.887-888.

Hyperemesis gravidarum
Hyperemesis gravidarum is persistent, uncontrolled vomiting that begins in .the first weeks of pregnancy and may continue throughout pregnancy. Unlike morning sickness, hyperemesis can have serious complications, including severe weight loss, dehydration, and electrolyte imbalance. NOTE: The defining factor for hyperemesis gravidarum should be the time of occurrence and that is the 2nd trimester, usually the 14 16th week. If this is on the 1st trimester, usually this is morning sickness. Causes Gonadotropine production Psychological factors Trophoblastic activity Assessment Findings Continuous, severe nausea and vomiting Dehydration Dry skin and mucous membranes Electrolyte imbalance Metabolic acidosis Non-elastic skin turgor


Oliguria Diagnostic Test Result Arterial blood gas and analysis reveals alkalosis. Hb level and HCT are elevated. Serum potassium level reveals hypokalemia Urine ketone levels are elevated. Urine specific gravity is increased. Nursing Diagnoses Fluid volume deficit Altered nutrition; less than body requirements Pain Treatment Total parenteral nutrition (TPN) Restoration of fluid and electrolyte balance Drug Therapy Anti-emetics, as necessary for vomiting, for example Plasil , Hydroxyzine and Prochlorperazine Intervention and Rationales Monitor vital signs and fluid intake and output to assess for fluid volume deficit. Obtain blood samples and urine specimens for laboratory tests, including Hb level, HCT, urinalysis, and electrolyte levels. Provide small frequent meals to maintain adequate nutrition. Maintain I.V. fluid replacement and TPN to reduce fluid deficit and pH imbalance. Provide em0otional support to help the patient cope with her condition.

Teaching Topics Using salt on foods to replace sodium lost by vomiting. From: Springhouse, pages 483-484


Intrapartum period extends from the beginning of contractions that cause cervical dilation to the first 1-4 hours after delivery of the newborn and placenta. Intrapartum care refers to the medical and nursing care given to a pregnant woman and her family during labor and delivery. Labor versus Labor 1. Labor: Coordinated sequence of involuntary uterine contractions or a result in the effacement and dilation of the cervix, followed by expulsion of the products of conception. 2. Delivery: Actual event of birth


A. Factors Affecting Labor

FACTORS AFFECTING LABOR PASSAGEWAY Gynecoid Anthropoid Android Platypelloid PASSENGER Fetal bones Suture lines Fontanels head measurements Fetal lie Fetal attitude Fetal presentation Fetal position Fetal station POWERS PHASES > Increment > Acme > Decrement ASSESSMENT Frequency Duration Interval Intensity PLACENTAL FACTORS Abruptio placenta Placenta previa Placenta acreta Placenta media PSYCHE Stress factors Leading to hypotonia

-refers to the adequacy of the pelvis and birth canal in allowing the fetal descent; factors include: A. Type of pelvis B. structure of the pelvis (true versus false pelvis) C. pelvic inlet diameters D. ability of the uterine segment & vaginal canal to distend, the cervix to dilate AFFECTED BY THE FOLLOWING FACTORS:

A. Types of Structure
Parts: ischium, iluim, coccyx. Joints: Sacroiliac, Sacrococcygeal, symphysis pubis (all soften during pregnancy)


Classifications or Types of Pelvis: a. Gynecoid: Normal Female Pelvis: Rounded Oval. MOST FAVORABLE FOR SUCCESSFUL LABOR & BIRTH. Android: Normal Male Pelvis: Funnel Shape Anthropoid: oval Platypelloid: flattened, transverse oval

b. c. d. e. B. Structure of the Pelvis (with pelvic inlet & outlet diameters)


FALSE PELVIS Above the linea terminalis, across the top of symphysis pubis. It supports the enlarge uterus in the abdominal cavity Shallow upper basin of the pelvis Supports the enlarging uterus but not important obstetrically LINEA TERMINALIS Plane dividing upper or false pelvis from lower or true pelvis TRUE PELVIS Lies below the linea terminalis, the bony pelvis through which the baby pass Widest diameter (transverse) Narrowest diameter (anterior posterior) Consists of the pelvic inlet, pelvic cavity, and pelvic outlet. Bony canal through which the infant pass. Measurements of true pelvis influence the conduct and progress of labor and delivery. MIDPLANE Pelvic cavity

OUTLET Widest diameter: Anterior posterior diameter (requires the internal Relationship of fetal head for entry) Narrowest diameter: Transverse Intertuberous Diameter (facilitates delivery in Occipital Anterior Posterior) B1.

Pelvic measurements
a. True conjugate or conjugate vera - measured from upper margin of symphysis pubis to sacral promontory; should be at least 11 cm. - may be obtained by x-ray or U/S b. Tuber-ischial diameter/ Intertuberous diameter - Measures the outlet between the inner borders of ischial tuberosities, should be at least 8-9 cm. - estimated on pelvic exam c. Obstetrical Conjugate - Distance between the inner surfaces of the symphysis pubis and sacral promontory


Refers to the fetus and its ability to move through the passageway.


AFFECTED BY THE FOLLOWING FACTORS: a. Attitude 1. The relationship of the fetal body parts to one another or, another word is fetal posture 2. Normal intrauterine attitude is flexion, in which the fetal back is rounded, the head is forward on the chest, and the arms and legs are folded in against the body B Lie - Relationship of the spine of the fetus to the spine of the mother Transverse lie is an indication for cesarean delivery. Several maternal and fetal conditions make cesarean delivery necessary .The commonly accepted indications include complete placenta previa, transverse lie at term, cephalopelvic disproportion, abruptio placentae, active genital herpes, umbilical cord prolapse, failure to progress in labor, proven fetal distress, benign and malignant tumors that block the birth canal, and cervical cerclage. Other reasons for a cesarean delivery are more contraversial, such as breech presentation, previous cesarean birth, major congenital anomalies, and severe isoimmunization. Twins can sometimes be delivered vaginally, especially when the lowermost twin is in a vertex presentation. 1... Longitudinal or vertical a. Fetal spine is parallel to the mother's spine b. Fetus is either cephalic or breech presentation 2... Transverse or horizontal a. Fetal spine is at a right angle, or perpendicular, to the mother's spine b. Presenting part is the shoulder c. Delivery by cesarean section 3... Oblique a. Fetal spine is at a slight angle from a true horizontal lie b. Delivery is by cesarean section if uncorrectable C Presentation - the relationship of a particular reference point of the presenting part and the maternal pelvis described with a series of 3 letters or presentation refers to the part of the fetus at the cervical os Presenting part: Portion of the fetus that enters the pelvis first 1. Cephalic a. The most common presentation b. Fetal head presents first 2 Breech a. Buttocks present first b. Delivery by cesarean section may be required, although it is often possible to deliver vaginally 3 Shoulders a. Fetus is in a transverse lie, or the arm, back, abdomen, or side could present b. If the fetus does not spontaneously rotate or if it is not possible to turn the fetus manually, a cesarean section may be performed NOTE: The nurse would auscultate above the umbilicus if the fetus is in breech presentation has the back above or at the umbilical area. Fetal heart tones are ausculated best in the left lower abdomen when the fetus is in a left occipitoanterior position. For the heart tones to be located below the umbilicus, the fetus would be in a cephalic position. Fetal heart tones are heard best in the right lateral abdomen when the fetus is in a right occipitoposterior position.


D. Position Relationship of assigned area of the presenting part or landmark to the maternal pelvis or the relationship of the fetus's presenting part to the mother's pelvis LEOPOLD'S MANEUVERS It is a systematic way to evaluate the presentation, position and attitude of the fetus; the location of the best place to auscultate the fetal heart sounds; and the engagement status of the presenting part. They dont accurately determine how large the fetus is, which is best determined by ultrasound. Preparation 1. Ask the mother to empty the bladder 2. Warm hands and apply them to the abdomen with firm and gentle pressure PROCEDURE The first maneuver determines what fetal part is in the fundal portion of the uterus. In this case, the soft, firm mass indicated the fetal buttocks are in the fundus, reflecting a vertex presentation. The second maneuver documents the location of the fetal back. The side of the uterus where the back is located is smooth and convex to the touch, and the opposite side has areas of indentation. The third maneuver confirms that was what palpated in the fundus is correct and also determines whether the presenting part is engaged. In this case, the hard, round, movable object in the pubic area is the fetal head. The fourth maneuver determines id the fetal head is flexed or extended. Fetal Position ROA: Right occiput anterior LOA: Left occiput anterior (the best fetal position) ROP: Right occiput posterior RMA: Right mentum anterior RMP: Right mentum anterior LOP: Left occiput posterior LMA: Left mentum anterior ROT: Right occiput transverse LOT: Left occiput transverse RMP: Right mentum posterior LSA: Left sacrum anterior LSP: Left sacrum posterior Severe back pain during labor maybe related to a fetus in an OCCIPITO- POSTERIOR POSITION. This means that the fetal head presses against the clients sacrum, which causes marked discomfort during contractions. Repositioning the client and providing sacral back rubs may help alleviate the discomfort. Transverse, oblique and occiput positions do not cause pressure on the sacrum. 5. Fetal Lie - refers to the relationship of the fetal long axis to that of the mother's long axis. a. CEPHALIC vertex, face, brow b. BREECH frank, footling, complete c. SHOULDER transverse lie NOTE: Adolescent clients maturation are usually not yet complete, therefore they are very common for cephalopelvic disproportion. NOTE: Lie (spine to spine) may be longitudinal (parallel), transverse (right angles), oblique (slight angle off true transverse lie).










- Refers to the frequency, duration, and strength of uterine contractions to cause complete cervical effacement and dilation. The forces acting to expel the fetus

1. Effacement: Shortening and thinning of the cervix during the first stage of labor 2. Dilation: Enlargement of cervical os and cervical canal during first stage

1. INCREMENT- steep crescent slope from beginning of the contraction 2. ACME/PEAK strongest intensity. 3. DECREMENT diminishing intensity.

until its peak.

FREQUENCY beginning of one contraction to beginning of one contraction. Less than 2 minutes should be reported. DURATION beginning of one contraction until its completion. More than 90 seconds should be reported because of uterine rupture or fetal distress. INTENSITY the strength of contraction at its peak may be mild, moderate or strong.


- Refers to the site of placental insertion.

- Refers to the clients psychological state, available support systems, preparation for birth, experiences, and coping strategies.

1. Signs of impending labor 2. Comparison of True Labor from False Labor 3. Stages of labor 3. a. station of the presenting part 4. Nursing Interventions during labor & delivery 5. Assessing the Fetal Heart Rate SIGNS OF IMPENDING LABOR Lightening Braxtons-Hicks contraction Gastrointestinal upset Burst of energy Blood show

#1 sign of labor Ruptured bag of water


1. PREMONITORY SIGNS OF LABOR 1. LIGHTENING - Descent of the fetus and uterus into pelvic cavity before labor -Occurs 2-3 weeks earlier in primipara. - In multipara, may not occur until labor begins. 2. CERVICAL CHANGES a. EFFACEMENT - Progressive softening ripening and thinning of the cervix. - BLOODY SHOW (expulsion of mucous plug) b. DILATION - Opening of cervical os during labor. 3. Regular Braxton Hicks contractions. 4. Rupture of amniotic membranes. 5. NESTLING BEHAVIORS 6. Weight loss of about 1-3 lbs 2-3 days before labor onset. 2. COMPARISON OF TRUE AND FALSE LABOR CHARACTERISTICS Contractions


Discomfort Effects of walking Cervical changes Show During sleep During Sedation 3. 1ST STAGE Contraction to dilation Preparatory division: 1) Latent phase 0-3 cm Duration: 30 45 seconds NOTE: Pushing during the first stage of labor when the urge is felt but the cervix is not yet fully dilated may produce cervical swelling and makes labor more difficult. The client should be encouraged to PANT BLOW or BLOW-BLOW pattern of

TRUE Regular Become more frequent Gradual increase in duration and intensity / progressive frequency & intensity Begins at lower back and radiates around abdomen Contractions are intensified Progressive dilation and effacement Present Pain doesnt disappear Contractions doesnt stop

FALSE Irregular Unchanged Unchanged or decrease in frequency and intensity

Primarily on the lower abdomen & groin Lessened or not affected No change Not present Pain disappears Contractions stops

STAGES OF LABOR 2ND STAGE Full cervical dilatation to delivery 3RD STAGE Delivery to placental expulsion The nurse should know if the placenta is going to be delivered, is to watch for cord lengthening, a slight gush of darkened blood or a change in fundal shape. 4TH STAGE 1st 4 hours postpartum The precautions you should take when a postpartum client starts ambulating are the fall precaution and close monitoring should be done due to the risk of syncopy, especially the first few times out of bed.


breathing to help overcome the urge to push.

2) Active phase 4-7 cm Duration: 45-60 seconds 3) Transitional phase 8-10 cm Duration : 60-90 seconds

FIRST STAGE OF LABOR (ONSET OF REGULAR CONTRACTIONS TO FULL CERVICAL DILATION TRANSITION PHASE TIME: PRIMIPARA (1hour) MULTIPARA (10 15 minutes) CERVIX: EFFACEMENT - 100% DILATION - 8-10 cm CONTRACTIONS FREQUENCY - 2-3 minutes DURATION - 60-90 seconds MANIFESTATIONS: Client may be irritable and panicky; May lose control; Amnesic between contractions; Perspiring, nauseous and vomiting common; Trembling of legs; Pressure on bladder and rectum; Backache; Increased show; Circumoral pallor NOTE: If the client is in active labor and there is no change in dilation after 2 hours, the nurse should suspect cephalopelvic disproportion. The client is not experiencing a prolonged latent phase (0-3 cm), prolonged transitional phase (pushing), and contraction pattern. NOTE:Vaginal Examination To determine if the client is fully dilated, the nurse performs a vaginal examination. To assess the suture most readily felt, the nurse would determine the position of the cranial suture termed-SAGITALL SUTURE.


STATION Refer to the level of presenting part of fetus in relation to imaginary line between ischial spines (zero station) in mid pelvis of mother. - The measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine Minus station: above ischial spine -5 to 1 indicates a presenting part above zero station (-3FLOATING, -1 DIPPING) Station 0: at ischial spine 0 means ENGAGEMENT Plus station: below ischial spine + 1 TO + 5 indicates a presenting part below zero station +3 CROWNING My baby is coming, the #1 nursing intervention is to look for perineal bulging (crowning). If the perineum is bulging, the patient should be coached to pant with her contractions so that she doesnt push. Fetal heart rate is focus on the labor process or potential fetal cord compression and meconium stained complications SECOND STAGE OF LABOR (COMPLETE CERVICAL DILATION TO BIRTH OF NEWBORN) TIME PRIMIPARA (30-50 minutes ) MULTIPARA (20 minutes) CONTRACTIONS FREQUENCY - 2-3 minutes DURATION - 60-90 seconds INTENSITY VERY HARD: 100 mm Hg MANIFESTATIONS: Decrease in pain from transitional level; increased bloody show; Excited eager and in control. THIRD STAGE OF LABOR (DELIVERY OF NEWBORN TO DELIVERY OF PLACENTA) TIME: 5-30 minutes CONTRACTIONS


Strong and well-contracted uterus changing to globular shape MANIFESTATIONS: Increased gush of blood Uterus becoming globular with fundus rising in the abdomen Apparent lengthening of cord FOURTH STAGE OF LABOR (DELIVERY OF PLACENTA TO HOMEOSTASIS)

TIME Usually defined as the first hour postpartum. This stage lasts from 1-4 hours after birth. UTERUS The uterus contracts in the midline of the abdomen with the fundus midway between the umbilicus and symphysis pubis. MANIFESTATIONS: Lochia rubra Exploration of newborn Parent-infant bonding begins Newborn alert and responsive First period of reactivity NURSING INTERVENTIONS DURING LABOR AND DELIVERY During labor, monitor FHR. Provide patient comfort. Administer analgesics as indicated. Prepare for delivery. Immediate newborn care at delivery. - Establish airway. - Observe Apgar score at 1 and 5 minutes interval. - Clamp umbilical cord. - Maintain warmth. - Assess the newborns gestational age. - Administer prophylactic eye drops and vitamin K. - Place identification band on baby and mother. NURSING CARE DURING LABOR STAGE 1 PHASE Latent ASSESSMENT Onset of labor until cervical dilatation of 4 cm. NURSING CONSIDERATION Monitor frequency, intensity, and patterns of uterine contractions Monitor fetal status during labor by monitoring fetal heart rate Assess bloody show (pink or blood streaked mucus), perineal bulging, membrane status Periodic vaginal exams Monitor vital signs Assess clients ability to cope with


contractions Provide emotional support

From dilation to delivery of the fetus

Prep client for delivery Immediate assessment of the newborn Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate

. 3 From delivery of the fetus to delivery of the placenta, usual within 5-20 mins. Of delivery Assess umbilical cord for 3 vessels (2 arteries, 1 vein) Assess placenta for intactness The fundus should be midline at or two cm. Below the umbilicus By the 2nd postpartum day, the fundus should be firm and two fingerbreadths below the umbilicus. The fundus should be at the level of the umbilicus on the day of delivery and falls below the umbilicus by approximately one fingerbreadth (1 cm) per day, until it has contracted into the pelvis by the 9th or 10th day. The fundus should be firm, not soft. A soft or boggy fundus indicates that the uterus isn't contracting properly. The fundus should be palpated in the midline of the abdomen; if the woman has a full bladder, however, the fundus may be deviated to the right or left. The fundus should descend approximately 1-2 cm every 24 hours NOTE: The fundus should not be massaged unless it is relaxed. Constant massaging would tire the uterine muscle, contributing to hemorrhage Promote parent-infant bonding

The period of immediate recovery and


observation after delivery of the placenta. Approximately 2 hours

Assess maternal vital signs, fundal height, lochia and bladder distention

One hour after birth expect the fundal height at midway between the umbilicus and the symphysis pubis. Generally, the fundal height descends into the pelvis one fingers-breadth per day. Assist indicated breastfeeding efforts if

In teaching the client about postpartum weight loss in relation to breastfeeding the factors that should be considered is the caloric needs of a nursing mother and dieting should be avoided, in order to maintain adequate milk supply.



A. Description 2. Monitors uterine activity, assesses frequency, duration, and intensity of contractions, assesses FHR in relation to maternal contractions. It is the baseline FHR measured between contractions; the normal FHR is 120 to 160 beats per minute B. External fetal monitoring 1. Noninvasive and performed by the use of a tocotransducer or Doppler ultrasonic transducer 2. Perform Leopold's maneuvers to determine on which side the fetal back is located, and place the ultrasound transducer over this area (fasten with a belt) 3. Place the tocotransducer over the fundus of the uterus where contractions feel the strongest (fasten with a belt) 4. Allow the client to assume a comfortable position, avoiding vena cava compression NOTE: The external fetal monitor records the contractile pattern and the fetal heart rate response to the contractions. The external monitor doesnt accurately record intensity of the contractions, and it doesnt accurately record fetal heart rate variability. C. Internal fetal monitoring 1. Invasive and requires rupturing of the membranes and attaching an electrode to the presenting part of the fetus. NOTE: The patient with the fetus in a vertex position and meconium-stained fluid would have the highest priority of being monitored with internal fetal monitoring. The patient with the meconium-stained amniotic fluid is at high risk for fetal distress. Internal fetal monitoring requires that the patient have ruptured


membranes and be dilated at least 1 cm and that the fetal presenting part is reachable. In many institutions, fetal monitoring is used routinely on all patients. Fetal monitoring is most useful in situations in which a high probability exists of maternal contractile problems or fetal distress. Fetal monitoring provides an almost continuous recording of labor events. NOTE: Internal EFM can be applied only after the client's membranes have ruptured, when the fetus is at least at the 1 station, and when the cervix is dilated at least 2 cm. Although the client may receive anesthesia, it isn't required before application of an internal EFM device. 2. Mother must be dilated 2 to 3 cm to perform internal monitoring NOTE: To prevent exposure to human immunodeficiency virus (HIV), invasive procedures, such as fetal scalp sampling, and vacuum extraction, shouldnt be done unless absolutely indicated. Each of those procedures either causes or has the potential to use a break in the fetal skin, thereby increasing the risk of transmission of HIV to the fetus. Non-stress test and ultrasonography arent noninvasive procedures and dont increase the risk of transmission of HIV to the fetus. Sterile vaginal examinations are necessary to monitor the patients progress during labor and, if performed appropriately, shouldnt pose additional risk of HIV transmission to the fetus FETAL HEART RATE PATTERN Tachycardia (>160 b.p.m.) Bradycardia (<120 b.p.m.) INDICATIVE OF.. Maternal or fetal infection Fetal hypoxia (an ominous sign) Fetal hypoxia or stress Maternal hypotension after epidural initiation INTERVENTION Dependent upon cause

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

Head compression (not ominous) Vaginal stimulation Fetal stress and hypoxia Deficient placental perfusion Supine position Maternal hypotension Uterine hyperstimulation

Place client on left side Increase fluids (to counteract hypotension) Stop oxytocin (Pitocin) if in use Not required

Change maternal position Correct hypotension Increase I.V. fluid rate as ordered Discontinue oxytocin (Pitocin) NOTE: Nursing interventions for uteroplacental insufficiency include repositioning to side-lying position; administering oxygen by tight face mask at 10 to 12 L/minute; increasing I.V. fluids; discontinuing the oxytocin, if its being infused; assessing maternal vital signs for evidence of hypotension; and evaluating the fetal response to the



Variable deceleration (Transient decrease in anytime during contraction)


Cord compression Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position from supine to side-lying may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression. The first action when uterine cord occurs is to relieve pressure on the cord by changing the patients position. Once you have checked the cord, the rest of the body should be delivered with an application of gentle traction on the anterior shoulder, advising the patient not to push. If the cord is pulled on before the placenta has separated there will be a uterine inversion or retained placental fragments. Hypoxia or hypercarpnia Fetal sleep cycle Depressant drugs Hypoxia CNS anomalies

Administer oxygen as ordered . Change maternal position (left lateral position) Administer O2

Decreased baseline)



Dependent upon cause

Mechanisms of Labor Engagement or Cardinal movements by the Fetus

Definition: Mechanism by which the fetus nestles into the pelvis. A continuous process from the time of engagement until birth, and is assessed by the measurement called station Descent Also termed lightening or dropping Descent The process that the fetal head undergoes as begins its journey through the pelvis


Flexion Process of the fetal head's nodding forward toward the fetal chest Suboccipotobregmatic: the diameter that presents to the maternal pelvis during COMPLETE FLEXION. Internal Rotation Internal rotation of the fetus; most commonly from the occipital transverse position, assumed at engagement into the pelvis, to the occipital anterior position while continuously descending Extension Enables the head to emerge when the fetus is in a cephalic position Begins after the head crowns Is complete when the head passes under the pubis and occipital, and the anterior fontanel, brow, face, and chin pass over the sacrum and coccyx are over the perineum Restitution Realignment of the fetal head with the body after that head emerges External Rotation The shoulders externally rotate after the head emerges and restitution occurs, so that the shoulders are anteroposterior diameter of the pelvis Expulsion The delivery baby


Descent Expulsion


Internal Rotation


External Rotation








Figure 18 Cardinal Movements or Mechanism of labor

Analgesia administered during the second stage of labor includes continuation of the lumbar epidural block, pudendal block, and local infiltration of the perineum. Narcotic analgesics and pericervical block are administered during the active phase of labor. A spinal block is given during the active phase of the first stage of labor. Sedative hypnotics, if administered, are given when the patient is in early latent labor to encourage rest. A spinal block is given during the active phase of the first stage of labor.

NOTE: NOTE: The chief concepts of Lamaze teaching include conditioned responses to stimuli through use of a focal point. An emotionally satisfying experience is promoted rather than discouraging use of analgesia and anesthesia. A. Local anesthesia 1. Used for blocking pain during episiotomy 2. Administered just before the birth of baby 3. No effect on the fetus B. Paracervical block 1. Used in the first stage of labor 2. Provides a rapid block of uterine pain 3. No effect on the perineal area 4. No effect on the ability to bear down 5. May cause fetal bradycardia


C. Pudendal block 1. Administered just before the birth of the baby 2. Injection site at pudendal nerve through a transvaginal route 3. Blocks perineal area for episiotomy 4. Effect lasts about 30 minutes 5. No effect on contractions or fetus NOTE: Pudendal Block Anesthesia The #1 purpose is to relieve pain primarily in the perineum and vagina. It does not relieve pain primarily in the perineum and vagina. Pudendal block is adequate for episiotomy and its repair. The fetus should be assessed for BRADYCARDIA which is a potential complication of pudendal block anesthesia. Decrease movements, increase variability and meconium stained are NOT associated. Maternal Adverse effects are the following: hypotonia, reduced responsiveness and seizures.

D. Epidural block 1. Injection site in epidural space at L3-L4 2. Administered after labor is established or just before a scheduled cesarean birth 3. Relieves pain from contractions and numbs vagina and perineum 4. May cause hypotension 5. Does not cause headache because the dura mater is not penetrated 6. Assess maternal blood pressure 7. Maintain the mother in side-lying position or place a rolled blanket beneath the right hip to displace the uterus from the vena cava 8. Administer IV fluids as prescribed 9. Increase fluids as prescribed if hypotension occurs 9. The major complication of epidural anesthesia is maternal hypotension. NOTE: To minimize the hypertensive effects of epidural anesthesia prior to the procedure adequately hydrate the patient and position the patient side lying to the left. After epidural anesthesia the vital signs should be monitored every 1-2 minutes for the first 15 minutes. The assessment should be a high priority after a patient has received an epidural is blood pressure because an epidural can cause hypotension and its blocks the autonomic nervous system. A patient who is about to receive epidural anesthesia should empty her bladder before the procedure because an epidural will lessen the sensation to void so voiding now may decrease the need for catheterization later. NOTE: A common adverse effect of epidural anesthesia is hypotension, which would cause impaired gas exchange in the fetus. To prevent hypotension, the patient receives a bolus of 500 to 1,000 ml of I.V. fluid before the procedure. The patient isnt affected by these problems because she didnt receive the epidural anesthesia. NOTE: The patient plans to receive an epidural anesthetic for pain relief during labor, it wont be administered until the patient is dilated 4 to 5 cm.

E. Spinal block 1. Injection site in spinal subarachnoid space at L3-L5 2. Administered just before birth 3. Relieves uterine and perineal pain and numbs vagina, perineum, and lower extremities


4. May cause maternal hypotension 5. May cause postpartum headache 6. The mother must lie flat 8 to 12 hours following spinal injection 7. Place a rolled blanket under the right hip to displace the uterus from the vena cava 8. Administer IV fluids as prescribed F. General anesthesia 1. May be used for some surgical interventions 2. The mother is not awake 3. Presents a danger of respiratory depression vomiting



Oxytocin Induction 1. A deliberate initiation of uterine contractions this stimulates labor 2. Elective induction may be accomplished I oxytocin (Pitocin) infusion 3. Obtain baseline tracing of uterine contractions and FHR 4. Increase IV dosage of oxytocin as prescribed only after assessing contractions, FHR, and maternal blood pressure and pulse 5. Do not increase rate of oxytocin once the desired contraction pattern is obtained (contraction frequency of 2 to 3 minutes and lasting 60 seconds) 6. Discontinue oxytocin as prescribed contraction frequency is less than 2 minutes or duration more than 90 seconds, or if fetal distress is note NOTE: Oxytocin (Induction of Labor) Before the induction of Labor, the nurse should obtain a baseline measurement of the fetal heart rate. If the fetal heart rate pattern shows fetal distress, the client is not a candidate or if contractions occur less than 2 minutes apart or last longer than 60 seconds

C. Amniotomy 1. Artificial rupture of membranes (AROM); performe by the physician to stimulate labor 2. Performed if the fetus is at "0" or "+" station 3. Increases risk of prolapsed cord and infectic 4. Monitor FHR before and after AROM 5. Record time of AROM, FHR, and characteristic of fluid 6. Meconium-stained amniotic fluid may be associated with fetal distress 7. Bloody amniotic fluid may indicate abrupt placentae or fetal trauma 8. An unpleasant odor to amniotic fluid is associated with infection 9. Polyhydramnios is associated with maternal diabetes and certain congenital disorders 10. Oligohydramnios is associated with intrauterine growth retardation (IUGR) and congenital disorders

D .External version


1. External manipulation of the fetus from an abnormal position into a normal presentation 2. Indicated for an abnormal presentation that exists after the 34th week 3. Monitor vital signs 4. If the mother is Rh-negative, ensure that RH immune globulin was given at 28 weeks gestation 5. Prepare for nonstress test to evaluate fetal well-being 6. IV fluids and tocolytic therapy may be administered to relax the uterus and permit easier manipulation of fetus 7. Ultrasound is used during the procedure to evaluate fetal position and placental placement and guide direction to the fetus 8. Abdominal wall is manipulated to direct fetus into a cephalic presentation if possible 9. Monitor blood pressure to identify vena cava compression 10. Monitor for unusual pain 11. Following the procedure a. Perform nonstress test to evaluate fetal well-being b. .Monitor for uterine activity, bleeding, ruptured membranes, and decreased fetal activity c. With Rh-negative clients, perform Kleihauer Betke test as prescribed to detect the presence and amount of fetal blood in the maternal circulation and to identify clients who need additional Rh immune globulin i. Episiotomy = The purpose of episiotomy is to shorten the 2nd stage of labor, substitutes a clean surgical incision for a tear and decreases undue stretching of perineal muscles. An episiotomy helps prevent tearing of the rectum but does not necessarily relieve pressure on the rectum. An episiotomy does not prevent perineal edema, ensure quick delivery of the placenta or cause enlarging the pelvic inlet. 1. Incision made into perineum to enlarge vaginal outlet and facilitate delivery 2. Check episiotomy site 3. Institute measures to relieve pain 4. Provide ice pack during the first 24 hours 5. Instruct the client in the use of sitz baths 6. Apply analgesic spray or ointment as prescribed 7. Provide perineal care, using clean technique 8. Instruct the client in the proper care of the incision 9. Instruct the client to dry the perineal area from front to back and to blot the area rather than wipe it 10. Instruct the client to shower rather than bathe in a tub 11. Apply a peripad without touching the inside surface of the pad 12. Report any bleeding or discharge to the physician 13. The advantage of an episiotomy is that it facilitates the delivery of the fetus, it prevents tearing of the perineum, and it prevents undo stretching of the perineal muscles.

F. Forceps delivery 1. Two double-crossed, spoon like articulated blades that are used to assist. in the delivery of the fetal head 2. Reassure the mother and explain the need for forceps 3. Monitor mother and fetus during delivery possible injury 5. Assist with repair of any lacerations


G. Vacuum extraction 1. A cap like suction device is applied to the fetal head to facilitate extraction 2. Suction is used to assist in delivery of the fetal head 3. Traction is applied during uterine contractions until descent of the fetal head is achieved 4. The suction device should not be kept in place any longer than 25 minutes 5. Monitor FHR every 5 minutes if external fetal monitoring is not used 6. Assess newborn infant at birth and throughout postpartum period for signs of cerebral trauma 7. Monitor for developing cephalohematoma 8. Caput succedaneum is normal and will resolve in 24 hours H. Cesarean delivery 1. Delivery of the fetus usually through a trans-abdominal, low-segment incision of the uterus 2. Preoperative a. If planned, prepare the mother and partner b. If an emergency, quickly explain the need and procedure to the mother and partner c. Obtain informed consent d. Make sure that the preoperative diagnostic tests are done, including the Rh factor e. Prepare to insert an IV line and a Foley catheter f. Prepare the abdomen as prescribed g. Monitor the mother and fetus continuously for signs of labor h. Provide emotional support i. Administer preoperative medications as prescribed 3. Postoperative a. Monitor vital signs b. Provide pain relief c. Encourage turning, coughing, and deep breathing d. Encourage ambulation e. Monitor for signs of infection and bleeding f. Burning and pain on urination may indicate a bladder infection g. A tender uterus and foul-smelling lochia may indicate endometritis h. A productive cough or chills may indicate pneumonia


Preterm Labor
Preterm labor is labor that begins after 20 weeks gestation and before 37 weeks gestation. ETIOLOGY PROM Incompetent cervix Multiple gestation SIGNS /SYMPTOMS Low back pain Suprapubic pressure Vaginal pressure ASSESSMENT Obtain thorough obstetric history Obtain specimen for CBC & U/A Determine frequency, duration &


Previous history of Preterm labor DES exposure Emotional stress Hydramnios Placenta previa Abruptio placenta Maternal age <18 or >35

Rhythmic uterine contractions (2 uterine contractions lasting 30 seconds within 15 minutes) Cervical dilatation <4 cm & effacement 50% or less Expulsion of cervical mucus plus Bloody dhow

intensity of uterine contractions Determine cervical dilatations and effacement Assess status of membranes and bloody show Evaluate fetus for distress, size and maturity

MANAGEMENT Goal: PREVENTION OF PRETERM DELIVERY Conservative Treatment: Bed rest in lateral position Hydration w/ IVF and continuous fetal and uterine contraction monitoring Tocolytic Therapy: Beta mimetic agents: Ritodrine (Yutopar) Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia. Ritodrine (Yutopar) can cause tremor and jittery feelings, so it must be assessed whether the feelings are from the medication or from the Preterm labor Steroid therapy PROM (Premature Rupture of Membrane)

NURSING MANAGEMENT Perform measures to manage or stop Preterm labor Place on CBR in side-lying position Prepare fro possible ultrasound, amniocentesis, tocolytic and steroid therapy Administer meds as prescribed Assess S/E such as hypotension, dyspnea, chest pain and FHR exceeding 180 b.p.m. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy. Provide adequate hydration Provide emotional support

- Spontaneous rupture of amniotic membranes prior to onset of labor, maybe preterm gestation) or term ASSESSMENT CONTRIBUTING FACTOR Incompetent cervix Trauma Infection SIGNS AND SYMPTOMS 1. Leakage of amniotic fluid 2. pH higher than 6.5 3. Nitrazine paper reaction = blue RISK FOR: 1. Prolapsed cord 2. Infection 3. RDS

(before 38 weeks

MANAGEMENT MANAGEMENT: With infection: antibiotics and delivery of infant Without infection: 34-36 weeks of gestation= delay birth, amniocentesis and monitor LS ratio of the baby 28-32 weeks of gestation= delay birth, administer steroids to hasten maturity of the lungs and decreased RDS The good indicator of fetal lung maturity in a pregnant diabetic is presence of phosphatidglycerol in the amniotic fluid.

A. Umbilical cord prolapse


If the fetus is at 2 station and the membranes rupture, the patient is at risk for prolapsed cord. You can determine if a prolapsed cord exists if you perform a vaginal exam. PROLAPSE UMBILICAL CORD

Figure 23 Definition Synonyms Predisposing Factors PROLAPSE UMBILICAL CORD The umbilical cord is displaced, either between the presenting post and the amnion or protruding through the cervix. Cord Prolapse Fetal Position other than cephalic presentations Prematurity: NOTE: Small fetus allows more space around presenting part. Polyhydramnios Multiple fetal gestation FetoPelvic disproportion Abnormally long umbilical cord. Placenta Previa Intrauterine tumors that prevent the presenting part from engaging > Breech presentation, Transverse lie, Unengaged presenting part, Twin gestation, Hydramnios Small fetus Cord Prolapse: NOTE: first discovered when there is variable decelerated pattern FHR pattern variable: Decelerations with contractions or between contraction or fetal bradycardia present Persistent non reassuring fetal heart rate fetal distress Atrophy of the umbilical cord & cord protruding from vagina Cord may be palpated in cervix/vagina Reflex constriction when cord is exposed to air Cool, moist skin Dystocia Rupture of Membrane spontaneously The cord may then present/visible @ the vulva. Note: Do not attempt to push the cord into the uterus. Amniotomy: Rupture of Membranes

Initial Sign

Late Sign Cardinal Sign

Confirmatory Test


Best Major Surgery Disease Complication

Cesarian Section if the cervix incompletely dilated. Fast vaginal delivery with forceps

#1 Maternal & Fetal Infection - Causing compression of the

cord and compromising fetal circulation OTHERS: Prematurity, Hypoxia, Meconium aspiration,Fetal death if delayed or undiagnosed

Best Position

Trendelenbergs position or Knee Chest position -which causes

the presenting part to fall back from the cord. Turn side to side -Helps may be elevated to shift to fetal presenting toward diaphragm.

Bedside equipment

Best Drug Nature of the drug History of the Disease Nursing Diagnosis

Eternal Electronic Fetal Heart Rate monitoring Oxygen with face-mask. Sterile hand glove Heparin IV To control intravascular coagulation in the pulmonary circulation Fetal nutrients supply Compression of the umbilical cord Fluid volume deficit related to active hemorrhage Altered tissue perfusion related to maternal vital organ and fetal related to hypovolemia Risk for infection related traumatize tissue NOTE: The nurses #1 priority action to a prolapse cord is to assess the fetal heart rate. A prolapsed cord interrupts the oxygen and nutrient flow to the fetus. If the fetus doesnt receive adequate oxygen, hypoxia develops, which can lead to central nervous system damage in the fetus. The primary goal with a prolapsed of the umbilical cord is to remove the pressure from the cord. Changing the maternal position is the first intervention. Acceptable positions include knee-chest, side-lying and elevation of the hips. The nurse may also perform a vaginal examination and attempt to push the presenting part off the cord. Administering the oxygen benefits the fetus only if circulation through the cord has been reestablished. Start or maintain an IV as prescribed. Use of large-gauge catheter when starting the IV for blood and large quantities of fluid intake. Administer oxygen by face mask to provide high oxygen concentration at 8 10L/min. Instruct patient to cleanse from the front to the back. Explain the importance of hand washing before and after perineal care. OTHER MANAGEMENT: Reposition client to trendelenburg or knee- chest position Oxygen Push presenting part upward Apply moistened sterile towels Delivery as soon as possible

Nursing Intervention

(Pillitteri, Maternal and Child Nursing, p.300) (Pillitteri, Maternal and Child Nursing, p.578-579)




- Difficult, painful, abnormal progress of labor of more than 24 hours 1. Powers/ uterine inertia/ contraction HYPERTONIC LABOR PATTERNS (Primary inertia) Latent phase of labor Rest and sedation Fetal monitoring HYPOTONIC LABOR PATTERNS (Secondary inertia) Active phase of labor Oxytocin and amnionity Cesarean section if labor does not resume Early analgesia Bowel or bladder distention Multiple gestation Large fetus Hydramnios Grandmultiparity


2. a. b.

Passageway Contracted pelvis Unfavorable pelvic shapes Management: i. Evaluate pelvic diameters ii. Continue labor with careful monitoring iii. Perform assisted vaginal or caesarean delivery


Psyche a. Fear, anxiety ad tension increase stress and decrease uterine contractility b. Stress interferes with the clients ability with her contractions c. Stress increase fatigue Management: i. Monitor clients psychologic response to labor ii. Determines clients level of stress iii. Provide support iv. Encouraged relaxation

D. Infection The infant is at risk to develop thrush if the pregnant woman has monillial infection at the time of vaginal delivery Infection







ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) a. Transmission A. Across the placental barrier B. During the process of labor and delivery C. Via breast milk -HIV can cross some membranes such as the placental barrier, the blood-brain barrier, vaginal mucosa, and (in the neonate) the walls of the gastrointestinal tract -Prenatal transmission from infected mother to fetus or newborn via transplacental transmission, via contamination with maternal blood during birth, or through breast milk b. Nursing Management Avoid procedures that increase the risk of prenatal transmission, such as amniocentesis and fetal scalp sampling Note that if the fetus has not been exposed to HIV in utero, the highest risk exists during delivery through the birth canal Never use scalp electrodes Avoid episiotomy to decrease the amount of maternal blood in and around the birth canal Promptly remove the neonate from the mother's blood following delivery

NOTE: HIV has been found to be transmitted through the breast milk from mother to baby. Therefore, breast feeding isnt recommended for a mother who is HIV-positive. While transmission rates of HIV infection from mother to infant range from 30% to 75%, professionals estimate the actual transmission rate at about 40% to 50%. The AIDS virus is passed transplacentally, so cesarean delivery will not prevent infection of the neonate. In options 3, transmission from mother to fetus\child can occur transplacentally throughout pregnancy, trough contact with the mothers blood and vaginal secretions at delivery and through ingestion of break milk. In the option 4, a newborn can be symptom-free at birth and still develop AIDS. A true diagnostic of HIV infection in neonates cannot actually be made until around 15 months of age.

G. Precipitate delivery - Labor that is completed within 3 hours A pregnant patient with a known history of crack cocaine use is in labor must be prepared for a precipitous labor and notify the neonatologist of the infants high-risk status. If a patient has a precipitous labor at risk, the result of the labor process would be laceration of the soft tissues, uterine rupture, and excessive uterine bleeding. ASSESSMENT NURSING INTERVENTION


Predisposing Factors: 1. Multiparity 2. History of rapid labor 3. Premature or small fetus 4. Large bony pelvis Risks:

Management: 1. Monitor client and fetus closely 2. Possibly administer tocolytic agents 3. Prepare for emergency birth

1. Perineal lacerations & Hemorrhage When delivering the neonate, you should deliver the head between contractions. This will prevent the head from being delivered too suddenly, thuds preventing a possible tearing of the perineum.
3. Fetal Cerebral trauma


Uterine Rupture

The two findings on physical exam indicate uterine rupture is loss of uterine contour and palpable fetal part. The number one risk factor for uterine rupture is previous cesarean section.

COMPLETE Sudden sharp abdominal pain during contractions Abdominal tenderness Cessation of contractions Bleeding into abdominal cavity & sometimes into vagina Fetus easily palpated, FHT ceased Signs of shock I. Amniotic fluid embolism

INCOMPLETE Abdominal pain during contractions Contractions continue, but cervix fail to dilate Vaginal bleeding may be present Rising pulse rate and skin pallor Loss of fetal heart tones

An amniotic fluid embolism is when the amniotic fluid leaks into the maternal bloodstream bThe causes of an amniotic fluid embolism are difficulty in labor, or hyperstimulation of the uterus. Polyhydramnios is an excessive amniotic fluid. MANIFESTATION Dyspnea Sharp, chest pain Pallor or cyanosis Frothy, blood-tinged mucus MANAGEMENT Oxygen CPR Intubation Delivery




A. LOCHIA discharge from the uterus during the first 3 weeks after delivery. Increasing Lochia as the day passes by may indicate Heparin Intoxication. LOCHIAL CHANGES LOCHIA RUBRA Dark red discharge occurring in the first 2-3 days. Contains epithelial cells, erythrocytes and decidua. Characteristic human odor. LOCHIA SEROSA Pinkish to brownish discharge occurring 3-10 days after delivery. Serosanguineous discharge containing decidua, erythrocytes, leukocytes, cervical mucus and microorganisms. Has a strong odor. LOCHIA ALBA Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery. Contains leukocytes, decidua,epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria. Has no odor.


Process of involution takes 4-6 weeks to complete. Weight decreases from 2 lbs to 2 oz. Fundus steadily descends into true pelvis; Fundal height decreases about 1 fingerbreadth (1 cm)/day; by 10-14 days postpartum, cannot be palpated abdominally.


C. Uterine Involution
1. Description a. The rapid decrease in the size of the uterus as it returns to the nonpregnant state b. Clients who breastfeed may experience a more rapid involution 2. Assessment a. Weight of the uterus decreases from 2 pounds to 2 ounces in 6 week b. Endometrium regenerates c. Fundus steadily descends into the pelvis d. Fundal height decreases about 1 fingerbreadth (1 cm) per day E. By 10 days postpartum, uterus cannot be palpated abdominally NOTE: Deviation of the fundus to the right or left and location of the fundus above the umbilical are signs that the bladder is distended NOTE: Height of the Umbilicus on the First Postpartum Day The height is usually SLIGHTLY below the umbilicus about 24 hours after delivery. The top of the umbilicus is normally MIDWAY between the umbilicus and the symphysis pubis.

D. Breasts
1. Breasts continue to secrete colostrum 2. A decrease in estrogen and progesterone levels after delivery stimulates increased prolactin levels, which promote breast milk production. 3. Breasts become distended with milk on the third day 4. Engorgement occurs in 48 to 72 hours in non breast feeding mothers. NOTE: Bradycardia is a normal physiologic change for 6-10 days postpartum

E. Gastrointestinal tract
1. Women are usually very hungry after delivery 2. Constipation can occur 3. Hemorrhoids are common



NOTE: Maternal temperature during the first 24 hours following delivery may rise to 100. 4` F (38`C) as a result of dehydration. The nurse can reassure the new mother that these symptoms are normal. Postpartum Exercise Supine Position with the knees flexed, and then inhale deeply while allowing the abdomen to expand and exhale while contracting the abdominal muscles. The purpose of this exercise is to strengthen the abdominal muscles. Examples are reaching for the knees; push ups and sits ups on the first postpartum day. Assess height, consistency, and location of the fundus Monitor color, amount, and odor of lochia Assess lochia and color volume Give RhoGAM to mother if ordered. RhoGAM promotes lysis of fetal Rh (+) RBCs. Administer RhoGam as prescribed within 72 hours postpartum to the Rh-negative client who has given birth to an Rh-positive neonate. Rhogam (D) immune globulin is given by intramuscular injection, Check episiotomy and perineum for signs of infection. Promote successful feeding. Non-nursing woman- tight bra for 72 hours, ice packs, minimizes breast stimulation. Nursing woman- success depends on infant sucking and maternal production of milk. Postpartum Blues (3-7 days) Normal occurrence of roller coaster emotions Sexual activities- abstain from intercourse until episiotomy is healed and lochia ceased around 3-4 weeks. Remind that Assess height, consistency, and location of the fundus breastfeeding does not give adequate protection. Assess breasts for engorgement Monitor episiotomy for healing ( assess dehiscence & evisceration) Assess incisions or dressings of cesarean birth client ( prone to infection) Monitor bowel status ( prone to constipation) Monitor I &0 Encourage frequent voiding (prevent urinary retention which will predispose the mother to uterus displacement & infection) Encourage ambulation ( to prevent thromboplebitis & paralytic ileus) Assess bonding with the newborn infant ( to prevent failure to thrive) NOTE: A positive bonding experience is indicated when the mother turns her face toward the baby to initiate eye-to-eye contact. Observation of new mothers has shown that a fairly regular pattern of maternal behaviors is exhibited at first contact with the newborn. The mother follows a progression of touching activities from fingertip exploration toward palmar contact to enfolding the infant with the whole hand and arm. The mother also increase the time spent in the en face position. The mother arranges herself or the newborn so that her face and eyes are in the same plane as in her infant.


IV. POSTPARTUM DISCOMFORTS A. Perineal discomfort Apply ice packs to the perineum during the first 24 hours to reduce swelling after the first 24 hours, apply warmth by sitz baths B. Episiotomy 1. Instruct the client to administer perineal care after each voiding 2. Encourage the use of an analgesic spray as prescribed 3. Administer analgesics as prescribed if comfort measures are unsuccessful C. Breast discomfort PREVENTION: The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND FREQUENTLY WITH FEEDINGS. The 2nd is EXPRESSING A LITTLE MILK BEFORE NURSING, MASSAGING THE BREASTS GENTLY OR TAKING A WARM SHOWER BEFORE FEEDING MAY HELP TO IMPROVE MILK FLOW. Placing as much of the areola as possible into the neonates mouth is one method. Other methods include changing position with each nursing so that different areas of the nipples receive the greatest stress from nursing and avoiding breast engorgement, which make I difficult for the neonate to grasp. In addition, nursing more frequently, so that a ravenous neonate is not sucking vigorously at the beginning of the feedings, AND FEEDING ON DEMAND to prevent over hunger is helpful. AIRDRYING THE NIPPLES AND EXPOSING THEM TO THE LIGHT HAVE ALSO BEEN RECOMMENDED. Warm Tea bags, which contain tannic acid also, will sooth soreness. WEARING A SUPPORTIVE BRASSIERE DOES NOT PREVENT BREAST ENGORGEMENT. APPLYING ICE and LANOLIN DOES NOT RELIEVE BREAST ENGORGEMENT. (Page 178 -179 lippincot) INTERVENTION: Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples. NOTE: Specific nursing care for breast Engorgement 1. Breastfeed frequently 2. Apply warm packs before feeding 3. Apply ice packs between feedings NOTE: Specific Nursing Care for Cracked nipples 1. Expose nipples to air for 10 to 20 minutes after feeding 2. Rotate the position of the baby for each feeding 3. Be sure that the baby is latched on to the areola, not just the nipple NOTE: Do not use soap on the breasts, as it tends to remove natural oils, which increases the chance of cracked nipples NOTE: Inverted Nipples Push the areola tissues away from the nipples, and then grasp the nipples to tease them out of the tissue. Using a Woolrich breast shield, which pushes the nipples through openings in the shield, also can help overcome inverted nipples


Phenylketonuria Routine Screening is done after the neonate has been breast feed for 48 hours. The LATERAL HEEL (HEEL STICK) is the best site because it prevents damage to the posterior tibial nerve and artery and plantar artery.

POSTPARTUM DISCHARGE TEACHINGS A. General Principles/Considerations

A. Breast Feeding The American Academy of Pediatrics recommends beginning breast feeding as soon as possible after delivery or during the first period of reactivity. A neonate that will be breast fed should not be given formula by bottle at this time. Many institutions provide sterile water for the initial feeding to assess for esophageal atresia. Because colustrum is not irritating if aspirated and is readily absorbed by the neonates respiratory system, breast feeding can be done immediately after birth. Colustrum contains antibodies that the neonate lacks, such as Immunoglobulin A. Breast feeding stimulates the oxytocin secretion, which causes the uterine muscles to contract. NOTE: Oral contraceptives containing estrogen are not recommended for breastfeeding mothers; progestin-only birth control pills are less likely to interfere with the milk supply 14. Baby will develop his or her own feeding schedule. Hormonal contraceptives may cause a decrease in the milk supply and are best avoided during the first 6 weeks after birth. NOTE: The condom is the only safe, non prescription contraceptive to use while a woman lactating and before there is normal uterine involution at this time.

NOTE: LET DOWN REFLEX OF THE BREAST Oxytoxin is the #1 factor that stimulates the let down reflex while Prolactin is the one that stimulates the acini cells to produce milk. A. First Breast Feeding

The mother should be encouraged to nurse frequently during the first few days after delivery. BREAST FEEDING FOR AT LEAST 7-10 MINUTES PER SIDE FOR THE LET DOWN REFLEX TO BEGIN. 2nd breast Feeding AFTER THE FIRST BREAST FEEDING, the mother should breast feed her infant 2-3 hours until her milk supply is established. Breast milk contents versus cows milk BREAST MILK is higher in fat content than cows milk; 35% - 55% of the calories in breast milk are from fat. Cows milk is higher in iron, sodium calcium & phosphorus. COWS MILK According to the American Academy of Pediatrics (AAP) recommends that infants be given breast milk of formula UNTIL 1 YEAR OF AGE. The AAP Committee decreed that cows milk could be substituted in the


SECOND 6 MONTHS OF LIFE, BUT ONLY IF THE AMOUNT OF MILK CALORIES DOES NOT EXCEDD 65% of total calories and iron is replaced by solid foods. The protein content o cows milk is too high, and therefore is poorly digested, and may cause gastrointestinal tract bleeding SUPPLEMENTING BREAST FEEDING WITH BOTTLED FEEDING Bottle supplements tend to cause a decrease in the breast milk supply and demand for breast feeding, AND SHOULD BE AVOIDED NOTE: Breast milk Storage Never store it in clean glass containers because immunoglobulins tend to stick to glass bottles and the containers should BE STERILE. The client should use STERILE PLASTIC CONTAINERS labeled with time, date and amount. Store breast milk at the refrigerator for 48 hours or in a freezer for 2 months. Frozen breast milk should be thawed in the refrigerator for a few hours, placed under warm tap water, then shake it. NOTE: START OF SOLID FOOD is usually 4 months. B. BURPING & FEEDING

BURPING Another word is bubbling the neonate should be done after 5 minutes of feeding, in the middle of the feeding, and at the end o the feeding.The neonate should be held in an upright position and patted on the back. POSITION FOR FEEDING The neonate should be placed on the right side, placing the patient on prone position has been associated with SIDS (Sudden Infant Death Syndrome) NOTE: If the bottle nipple is kept full of formula, the infant will suck less air, the infant is less likely to spit up and less likely to swallow air. Swallowing air can lead to colic. A bottle should never be propped because of the chance of aspiration. Burping should occur after each 2 oz. Burping frequently decreased the chance of spitting up. The nipple should be all the way in the infants mouth so the infant can create a good suck. NOTE: Bottle-fed infants are usually fed within the first few hours after birth. The nurse must determine if the newborn is ready for this feeding. Signs are indicative of readiness for feeding include presence of rooting and sucking reflexes, active bowel sounds, absence of abdominal dissension, and absence of signs of respiratory distress. NOTE: How to stimulate the Infants lips to take the nipple? Lightly brushing the neonates lips with nipple causes the neonate to open the mouth the begin sucking. Such techniques as pulling down on the chin, squeezing the cheek, or placing the nipple directly in the mouth force the mouth open or force the neonates to take the nipple. C. Psychological Adaptation

Taking-in Phase Taking-hold Phase Letting-Go

Postpartum blues: overwhelming sadness Postpartum depression Postpartum Psychoses

Rubin's Postpartum Phases of Regeneration (POSTPARTUM PSYCHOSOCIAL ADAPTATION)



3 Days

.During this time, food and sleep are a major focus for the client. In addition, she works through the birth experience to sort out reality from fantasy and to clarify any misunderstandings. This phase lasts 1 to 3 days after birth. The primary concern is to meet her own needs. Takes place 1-2 days postpartum Mother is passive and dependent; concerned with own needs. Verbalizes about the delivery experience. Sleep/food important. Mother focuses on her own primary needs, such as sleep and food Important for the nurse to listen and to help the mother interpret the events of delivery to make them more meaningful Not an optimum time to teach the mother about baby care TAKING HOLD PHASE (DEPENDENT/INDEPENDENT) The client is concerned regarding her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.

3-10 days postpartum Mother strives for independence and begins to reassert herself. Mood swings occur. May cry for no reason. Maximal stage of learning readiness. Mother requires reassurance that she can perform tasks of motherhood. Begins to assume the tasks of mothering An optimum time to teach the mother about baby care.

LETTING GO PHASE (INTERDEPENCE) 10 to 6 weeks postpartum Realistic regarding role transition. Shows pattern of life-style that includes the new baby but still focuses on entire family as a unit. Accepts baby as separate person. Mother may feel deep loss over separation of the baby from part of the body and may grieve over the loss Mother may be caught in a dependent/independent role, wanting to feel safe and secure yet wanting to make decisions Teenage mothers need special consideration because of the conflict taking place within them as part of adolescence

POSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN Increased bleeding, clots or passage of tissue. Bright red vaginal bleeding anytime after birth. Pain greater than expected. Temperature elevation to 100.4 F. Feeling of full bladder accompanied by inability to void. Enlarging hematoma. Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness; and visual disturbance. Pain, redness, and warmth accompanied by a firm area in the calf. Difficulty breathing, rapid heart rate, chest pain, cough, feeling of apprehension, pale, cold, or blue skin color



A. HEMORRHAGE CAUSES The #1 cause of POSTPARTUM HEMORRHAGE IS RETAINED PLACENTAL FRAGMENTS. Uterine atony and vaginal & cervical tears are associated with early postpartum hemorrhage The #2 cause is OVERDISTENTION OF THE UTERUS from more than (10) pounds, OTHERS ARE: 4000 gms, neonate, excessive oxytocin use, Polyhydramnios and Placental Disorders. You should assess for uterine atony after a c-section delivery. This is more common after a csection than after a vaginal delivery. SIGNS OF HEMORRHAGE Boggy uterus (does not respond to massage) A boggy uterus would be palpable above the umbilicus and would be soft and poorly contracted. Abnormal clots unusual pelvic discomfort or headache Excessive or bright-red bleeding Signs of shock Early Hemorrhage starts on the first 24 hours, or more than 500 ml of blood on the first 24 hrs in a Normal spontaneous delivery.. MANAGEMENT Fluid replacement Emergency lay Oxygen Vital signs Perineal pad count Psychological support

Massaging the lower abdomen after delivery is done to maintain a firm uterus, which will aid in the clumping down of blood vessels in the uterus, thereby preventing any further bleeding. BOGGY UTERUS Uterine atony means that the uterus is not firm or it is not contracting. The nurse should gently massage the uterus which will contract the uterus and make it firm. Clients who are predisposed are usually MULTIPLE GESTATION, POLYHYDRAMNIOS, PROLONGED LABOR and LGA (LARGE GESTATIONAL AGE fetus.

B. THROMBOPLEBITIS - Inflammation of the vein caused by a clot The positive Homans sign indicate is possibility of thrombophlebitis or a deep venous thrombosis that is present in the lower extremities. When assessing for Homans sign ask the patient to stretch her kegs out with the knee slightly flexed while dorsiflex the foot. A positive sign is present when pain is felt at the back of the knee or calf. It is normal for a patient on magnesium sulfate to feel tired because it acts as a central nervous depressant and often makes the patient drowsy. MANIFESTATION Edematous extremities Fever with chills Pain and redness in affected area Positive Homans sign C. INFECTION PREDISPOSING FACTORS Rupture of membranes over 24 hours before delivery MANIFESTATION Fever Chills MANAGEMENT Antibiotics Oxytocin MANAGEMENT Preventive CURATIVE Immobilize extremity Analgesics Anticoagulant Thrombolytics


Retained placental fragments Internal fetal monitoring Vaginal infection

Poor appetite General body malaise Abdominal pain Foul-smelling lochia

Puerperial infection is an infection of the genital tract. Early signs and symptoms of puerperial infection include chills, fever, and flu-like symptoms. It can occur up to one month after delivery.

Analgesics Maintain hygiene Semi-fowlers positions Vital signs Early ambulations Assess lochia

Bright red blood is a normal lochial finding in the first 24 hours after delivery. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.

MASTITIS ASSESSMENT: Elevated temperature, chills, general aching, malaise and localized pain Engorgement, hardness and reddening of the breasts Nipple soreness and fissures Inflammation of the breast as a result of infection Primarily seen in breastfeeding mothers 2 to 3 weeks after delivery but may occur at any time during lactation NURSING IMPEMENTATION: Instruct the mother in good hand washing and breast hygiene techniques Apply heat or cold to site as prescribed Maintain lactation in breastfeeding mothers Encourage manual expression of breast milk or use of breast pump every 4 hours Encourage mother to support, breasts by wearing a supportive bra Administer analgesics & antibiotics as prescribed

Postpartum Mood Disorders

MOOD DISORDERS Postpartum blues ASSESSMENT Onset: 1-10 days postpartum lasting 2 weeks or less Fatigue Weeping anxiety Mood instability Onset: 3-5 days lasting more than 2 weeks Confusion Fatigue Agitation Feeling of hopelessness and shame let down feeling Alterations in mood roller coaster emotions Appetite and sleep disturbance According to Rubin, dependence and passivity are typical during the

Postpartum depression Normal processes during postpartum include the withdrawal of progesterone and estrogen and lead to the psychological response known as "the blues." Postpartum depression is a psychiatric problem that occurs later in


postpartum and is characterized by more severe symptoms of inadequacy. Because the client's behavior is normal, notifying her physician and conducting a home assessment aren't necessary. Postpartum psychosis

taking-in period, which may last up to 3 days after delivery. A client experiencing postpartum depression demonstrates anxiety, confusion, or other signs and symptoms consistently. Maternal role attainment occurs over 3 to 10 months. Attachment also is an ongoing process that occurs gradually. Onset: 3-5 days postpartum Symptoms of depression plus delusions Auditory hallucinations Hyperactivity


best time for physical assessment is midway between feedings. The hungry is often fussy, irritable, making physical examination difficult. Manipulation after eating may cause the neonate to regurgitate or vomit. A. 1. Assessment General guidelines 1. Keep newborn warm during the examination 2. Begin with general observations; then perform assessments that are least disturbing to the newborn first 3. Initiate nursing interventions for abnormal findings 4. Document all abnormal findings 1. Observe or assist with initiation of respirations 2. Assess Apgar score 3. Note characteristics of cry 4. Monitor for nasal flaring, grunting, retractions, abnormal respirations 5. Obtain vital signs 6. Observe newborn for signs of hypothermia or hyperthermia 7. Assess for gross anomalies 2. Implementation 1. Suction mouth, then nares, with bulb syringe 2. Dry newborn and stimulate crying by rubbing 3. Maintain temperature stability; wrap newborn in warm blankets and place a stockinette cap on newborn's head NOTE: Temperature taking The best site without complications is the taking it in axilla. It is not advisable to put it in the mouth, anus or ear since all of them are sensitive. 4. Keep newborn with mother to facilitate bonding 5. Place newborn at mother's breast if breastfeeding is planned, or place on mother's abdomen 6. Place newborn in warmer INITIAL PHYSICAL EXAMINATION & CARE OF THE NEWBORN


7. Position newborn on side or abdomen or in modified Trendelenburg position to facilitate drainage of mucus 8. Ensure newborn's proper identification 9. Footprint newborn and fingerprint mother on identification sheet, per agency policies and procedures 10. Place matching identification bracelets on mother and newborn NOTE: Convection, Conduction, Radiation and Evaporation Evaporation occurs when wet surfaces such as neonates skin are exposed to air. Conduction of heat away from the body may occur when the neonate comes in direct contact with cold surfaces such as scale or cold stethoscope. Radiation is the transfer o heat to cooler objects that are not in direct contact with the neonate. Convection- keeping away the neonate from the air conditioning or cooling ducts prevents heat loss 3. Vital signs

APGAR CRITERIA APGAR SCORE COLOR HEART RATE REFLEX IRRITABILITY MUSCLE TONE RESPIRATORY EFFORT O Pale Absent No response Limp Absent 1 Body pink, extremities blue Less than 100 b.p.m. Grimace Some flexion Slow, irregular 2 Totally pink Over 100 b.p.m. Vigorous cry Actively moves Good cry

The components of Apgar scoring system are tone, color, irritability, respiration and heart rate. 1. Perform and record the Apgar score at 1 minute and at 5 minutes 2. If the score is less than 7 at 5 minutes, the Apgar score should be performed at 10 minutes 3. Assess each of five items to be scored, and assign value of 0 (very poor) to 2 (excellent) for each item 4. Add the points to determine the newborns total score a. A score of 7 to 10 indicates a health -indicates that the newborn is doing well. b. A score of 3 to 6 is considered moderately depressed c. A score of 0 to 2 is severely depressed - indicates that the newborn needs assistance. 1. Heart rate: 100 to 170 beats per minute (apical); assess for a full minute because of irregularities afterbirth 2. Respirations: 30 to 80 breaths per minute; assess or a full minute 3. Axillary temperature: 96.8 to 99 F 4. Blood pressure: 73/55 mm Hg 4. Body measurements 1. Length: 45 to 55 cm (18 to 22 inches) 2. Weight: 2500 to 4300 g (5.5 to 9.5 pounds) 3. Head circumference: 33 to 35.5 cm (13 to 14 inches)


4. Chest circumference: 30 to 33 cm (12 to 13 inches) and should be equal to or 2 to 3 cm less than the head circumference NOTE: Neonates Head versus Chest circumference At birth, the neonates head circumference is about 2cm LARGER THAN THE CHEST CIRCUMFERENCE. The Average Head circumference is 13 -14 inches (33-35 cm) , average Chest circumference is 12.5 to 14 inches ( 31-35 cm)

B . Head to Toe Newborn Assessment

CIRCULATORY STATUS UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord id clamped DUCTUS ARTERIOSUS constrict with establishment of respiratory function FORAMEN OVALE closes functionally as respirations established, but anatomic or permanent closure may take several months HEART RATE averages 140 b.p.m. BP 73/55 mmHg PERIPHERAL CIRCULATION acrocyanosis within 24 hours RBC high immediately after birth; falls after 1st week ABSENCE/ NORMAL FLORA INTESTINE Vitamin K Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung function; prevent alveolar collapse and respiratory distress syndrome RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for 1 full minute change noted during sleep or activity NOTE: Periodic apnea is common in preterm infants. Usually, gentle stimulation is sufficient to get the infant to breathe RENAL SYSTEM


Urine present in the bladder at birth but NB may not void doe 1st 12-24 hours

Later pattern is 6-10 voidings/ day indicative of sufficient fluid intake Urine is pale and straw colored initial voidings may leave brick-red spots on diaper ( d/t passage of uric acid crystals in urine) Infant unable to concentrate urine for the 1st 3 months DIGESTIVE SYSTEM IMMATURE CARDIAC SPHINCTER may allow reflux of food, burped, REGURGITATE- placed NB right side after feeding Newborn cant move food from lips to pharynx. Insert nipple well to mouth FEEDING PATTERS vary - Newborns may nurse vigorously immediately afterbirth or may need as long as several days to suck effectively - Provide support and encouragement to new mothers during this time as infant feeding is very emotional doe most mothers NOTE: Distinguishing Neonatal Vomiting from Regurgitation Vomiting is usually sour, looks like curdled milk due to HCL, with a sour odor, while regurgitation has no sour odor or curdling of milk, or occurs during or immediately after feeding. IMPORTANT CONSIDERATIONS: Breastfeeding can usually begin immediately after birth; bottle-fed


newborns may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after birth prior to a feeding with formula An infant with gastrostomy tube should receive a pacifier during feeding unless contraindicated to provide normal sucking activity and satisfy oral needs. At age4-6 months, an infant should begin to receive solid food foods one at a time and 1 week apart.

FIRST STOOL is MECONIUM - Black, tarry residue from lower intestine - Usually passed within 12-24 hours after birth If the amniotic fluid shows evidence of meconium staining, the physician most likely do immediately after delivery is to suction the oropharynx immediately after the head is delivered and before the chest is delivered. TRANSITIONAL STOOLS thin, brownish green in color After 3 days MILK STOOLS are usually passed a. MILK STOOLS for BF infant loose and golden yellow b. MILK STOOLS for FORMULATED FED- formed and pale yellow HEPATIC Liver responsible for changing Hgb into conjugated bilirubin, which is further changed into conjugated (water soluble) bilirubin that can be excreted Excess unconjugated bilirubin can permeate the sclera and the skin, giving a jaundiced or yellow appearance to these tissues


HEAT PRODUCTION in newborn accomplished by:

Metabolism of BROWN FAT - A special structure in NB is a source of heat - Increased metabolic rate and activity - Axillary temperature: 96.8 to 99F - Newborn cant shiver as an adult does to release heat Newborns are unable to maintain a stable body temperature because they have an immature vasomotor center, and unable to shiver to increase body heat. - NBs body temperature drops quickly after birth after stress occurs easily - Body stabilizes temperature in 8-10 hours if unstressed - Cold stress increases o2 consumption may lead to metabolic acidosis and respiratory distress NB develops own antibodies during 1st 3 months but at risk for infection during the first 6 weeks Ability to develop antibodies develops sequentially


Neonatal Physical Assessment Birth weight=2500-400 grams (5 lbs. 8oz. 8 lbs. 13 oz.) Length= 45.7 55.9 cm. (18-22 inches)



Head circumference=33-35 cm (2-3 cm. Greater than chest circumference) Anterior fontanel (diamond shape) = closes 12-18 months Posterior fontanel (triangle shape)= closes 2-3 months NOTE: The posterior fontanel is located at the intersection of the sagittal and lambdoid suture is the space between the pariental bones; the lambdoid suture separates the two parietal bones and the occipital bone Molding- asymmetry of head as a result of pressure in birth canal Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the baby's scalp during labor. Blood outside the vasculature in a newborn increases the possibility of jaundice as the newborn's body tries to reabsorb the blood . Caput succedaneum, which is simply soft tissue edema of the scalp, can occur in any labor and isn't limited to a prolonged second stage of labor.


Blue/ gray d/t scleral thinness; permanent color established w/in 3-12 mos. Lacrimal glands immature at birth; tearless cry up to 2 months Absence of tears is common because the neonates tear glands are not yet fully developed Transient strabismus Dolls eye reflex persist for about ten days Red Reflex: A red circle on the pupils seen when an ophthalmoscopes light is shining onto the retina is a normal finding. This indicates that the light is shining onto the retina . CONVERGENT STRABISMUS (CROSS EYED) It is common during infancy until age 6 months because of poor oculomotor coordination NOTE : Congenital Glaucoma Unequal size should be reported immediately.


Nose breathers for first few months of life Scant saliva with pink lips Epsteins Pearls - small shiny white specks on the neonates gums and hard palate which are normal Incurving of pinna and cartilage deposition Short and weak with deep fold of skin Characterized by cylindrical thorax and flexible ribs

appears circular since anteroposterior and lateral diameters are about equal Respirations appear diaphragmatic Nipples prominent and often edematous Milky secretion (witch's milk) common ( effect of estrogen)


Cylindrical with some protrusion; scaphoid appearance indicates diaphragmatic hernia Umbilical cord is white and gelatinous with two arteries and one vein and begins to dry within 1-2 hours after delivery

NOTE: Umbilical cord



Three vessels, two arteries and one vein, in cord; if fewer than three vessels are noted notify the physician Small, thin cord may be associated with poor fetal growth Assess for intact cord, and ensure that damp is cured Cord should be clamped for at least the first 4 hours after birth; clamp can be removed hen the cord is dried and occluded Umbilical clamp can be removed after 24 hours

MALE: includes rugae on the scrotum and testes descended into the scrotum Urinary meatus: Hypospadias (ventral surface) Epispadias (dorsal surface) NOTE: Meatus at tip of penis Testes descended but may retract with cold Assess for hernia or hydrocele

First voiding should occur within 24 hours

Pseudomenstruation possible (blood-tinged mucus) effect of estrogen First voiding should occur within 24 hours

FEMALE: labia majora cover labia minora and clitoris


All neonates have bowlegged and flat feet NOTE NORMAL FEATURES: Major gluteal folds even Creases on soles of feet Assess for fractures (especially clavicle) or dislocations (hip) Assess for hip dysplasia; when thighs are rotated outward, no clicks should be heard Some neonates may have abnormal extremities: Polydactyl (more than 5 digits on extremity) Syndactyl (two or more digits fused together)


Figure. Polydactyl and Syndactyl SPINE Should be straight and flat Anus should be patent without any fissure Dimpling at the base is associated with spina bifida A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS damage Assessment for Jaundice The #1 technique is to blanch the skin over the bony prominence such as the forehead, chest or tip of the nose. NOTE: Jaundice starts at the head first, spreads to the chest, then the abdomen, then the arms and legs, followed by the hands and feet, which are the last to be jaundiced. Jaundice in the first 24 hours after the birth is a cause for concern that requires further assessment. Possible causes of early jaundice are blood incompatibility, oxytocin induction, and severe hemolytic process. Acrocyanosis of the hands and feet is normal, resulting from sluggish peripheral circulation Mongolian Spots Gary, blue or black marks that are frequently found on the sacral area, buttocks, arms shoulders or other areas. Harlequins Sign Occurs on one side of the body turns deep red color. It occurs when blood vessels on one side constrict, while those on the other side of the body dilate. Acrocyanosis versus Central Cyanosis Acrocyanosis involves the extremities of the neonate, for example bluish hands and feet due to neonates being cold or poor perfusion of the blood to the periphery of the body. While central cyanosis, which involves the lips, tongue and trunk indicating HYPOXIA which needs further assessment by the nurse. . Epsteins pearls are small, white cysts on the hard palate or gums of the newborn. They are nor abnormal and will disappear shortly after birth. Milia are blocked sebaceous glands located on the chin and the nose of the infant. Hemangiomas / Vascular Tumors Nevi flammeus or port wine stains VERNIX CASEOASA Should not be removed by oil or hand lotion, because it is a protective layer of the neonate after birth, and it disappears after birth ( page 199 lippincot) Never remove it with alcohol or cotton balls, unless meconium skinned. NOTE: Vernix Caseosa Erythema toxicum neonaturum Telangiectasia Port wine stain (nevus flamus) Strawberry hemangioma Hemangioma is benign vascular tumor that may be present on the newborn



Figure 24 Hemangioma

Figure 25 Erythema toxicum neonaturum and Milia

C.GESTATIONAL ASSESSMENT PARAMETER EAR BREAST TISSUE FEMALE GENITALIA MALE GENITALIA HEEL CREASES NURSING ACTION Fold the pinna (auricle) forward Measure it Observe Observe Observe TERM born between 37-42 weeks gestation Pinna recoils (springs back) 3 mm Labia majora cover labia minora Scrotal sac very wrinkled Extend 2/3 of the way from the toes to the heel PRETERM born before 37 weeks gestation Pinna opens slowly or stays folded in very premature infants Less than 3 mm Labia minora are more prominent; vaginal opening can be seen Fewer shallow rugae on the scrotum Soles are smoother, creases extend less than 2/3 of the way from the toes to the heel



The rooting reflex is elicited by stroking the neonate's cheek or stroking near the corner of the neonate's mouth. The neonate turns the head in the direction of the stroking, looking for food. This reflex disappears by 6 weeks. Other options refer to other reflexes seen in neonates: The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonate's fingers close around it. This reflex disappears between ages 6 and 9 months. The Babinski reflex is elicited by stroking the neonate's foot, on the side of the sole, from the heel toward the toes. A neonate will fan his toes, producing a positive Babinski sign, until about age 3 months. The sucking reflex is seen when the neonate's lips are touched and lasts for about 6 months. PALMAR GRASP REFLEX Newborns fingers curl around the examiners fingers and the newborns toes curl downward. Palmar response lessens within 3-4 months Palmar response lessens within 8 months Rooting and sucking reflex usually disappears after 3-4 months but may persists for up to 1 year Symmetric & bilateral abduction & extension of arms and hands Thumb & forefinger form a C EMBRACE reflex Present at birth, complete response may occur up to 8 weeks A persistent response lasting more than 6 months may indicate the occurrence of brain damage during pregnancy A normal reflex in a young infant caused by a sudden loud noise. It results in drawing up the legs, an embracing position of the arms, and usually a short cry.




Figure 26 Moro Reflex or Embrace Reflex Beginning at the heel of the foot, gently stroke upward along the lateral aspect of the sole; then the examiner moves the fingers along the ball of the foot The newborns toes hyperextend while the big toe dorsiflexes Reflex disappears after the newborn is 1 year old Absence of this reflex indicates the need for a neurological examination The newborn simulates walking, alternately flexing and extending the feet The reflex is usually present 3-4 months While the newborn is falling asleep or sleeping, gently and quickly turn the head to one side



As the newborn faces the left side, the left arm & leg extend outward while the right arm & leg flex When the head is turned to the right side, the right arm & leg extend outward while the left arm & leg flex Usually disappears within 3-4 months a. Place the newborn on the abdomen b. The newborn begins making crawling movements with the arms and legs c. The reflex usually disappears after about 6 weeks

E. BASIC TEACHING NEEDS OF NEW PARENTS CORD CARE Cleanse the cord with alcohol and sometimes triple dye once a day Keep the area clean and dry Keep the newborns diaper below the cord to prevent irritation Signs of infection: redness, drainage, swelling, odor Notify physician for signs of infection NOTE: Note any bleeding or drainage from the cord Triple dye may be applied for initial cord care because it minimizes microorganisms and promotes drying; use a cotton-tipped applicator to paint the dye, one time, on the cord on 1 inch of surrounding skin

Application of 70% isopropyl alcohol to the cord with each diaper change and at least two r three times a day to minimize microorganisms and promote drying.

NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area. The umbilical cord dries and falls off about 14 days. Peroxide and lanolin promote moisture, which can inhibit drying and allow growth of bacteria. Water doesnt promote drying. It is best to care for the neonates umbilical cord area by cleaning it with cotton pledgets moistened with alcohol. The alcohol promotes drying and helps decrease the risk of infection. An antibiotic ointment maybe used instead of alcohol, because there are a lot of bacteria which is resistant against some bacteria. Other agents such as wipes, sterile water and soap & water are not as effective as alcohol.


Observe for bleeding, first urination Apply diaper loosely to prevent irritation Notify physician for signs of infection Encourage parent to talk to, hold, and sing to infant Promotes skin-to-skin contact between parent and infant Feedings are opportunities for parent-infant bonding Notify physician for signs of infection NOTE: Sense of Touch The most highly developed sense at birth that is why, neonates responds well to touch.


Figure 27 Premature infants sole creases, earlobe and premature female genitalia



PRE TERM INFANT A neonate born before 38 weeks age of gestation


Low birth weight

(Mosbys Comprehensive Review of Nursing for NCLEX-RN page 215) Low socioeconomic level Poor nutritional status Lack of pre natal care

Contributing factors


Cardinal signs

Multiple pregnancy Prior previous early birth Race (non whites have a higher incidence of prematurity than whites) Cigarette smoking The age of the mother ( the highest incidence is in mothers younger than age 20.) Order of birth ( early termination is highest in first pregnancies and in those beyond the forth ) Closely spaced pregnancies Abnormalities of the reproductive system such as intrauterine septum Infections ( specially urinary tract infections) Obstetric complications such as premature rupture of membranes or premature separation of the placenta Early induction of labor Elective cesarian birth

Abnormal laboratory values

Appears small and underdeveloped The head is disproportionately large ( 3 cm or more greater than chest size) Skin is thin with visible blood vessel and minimal subcutaneous fat pads Vernix caseosa is absent Both anterior and posterior fontanelles are small Decreased RBCs Decreased serum glucose Increased concentration of indirect bilirubin Decreased serum albumin NOTE: The normal range of urine output for a preterm baby is 1 to 2ml/kg/day. The normal specific gravity for a preterm baby is 1.020. The normal range for blood glucose level in a preterm baby is 40 to 60 mg/dl. Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own. Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn to establish clear airway. Intubations NOTE: head of the infant in neutral position with towel under shoulder.

Best procedure

Best position

Positioning the infant on the back with the head of the mattress elevated approximately 15 degrees to allow abdominal contents to


fall away from the diaphragm affording optimal breathing space. Best position for suctioning: Infant on the back and slide a folded towel or pad under shoulders to rise, head is in neutral position. Complications Anemia of prematurity Hyperbilirubinemia/ kernicterus Persistent patent ductus arteriosus Periventricular / intraventricular hemorrhage Respiratory distress syndrome Retinopathy of prematurity Retrolental fibroplasias are a complication that occurs if the infant is overexposed to high oxygen levels. Necrotizing enterocolitis 1. Preterm size laryngoscope ET tube Suction catheter with synthetic surfactant Isolettes (incubator) Naloxone (Narcan) Nature of the drug: Narcotic antagonist Side effects: Hypertension, irritability, tachycardia Surfactan ( Survanta) Nature of the drug: Lung surfactant to improve lung compliance Side effect: Transient bradycardia, rales Vitamin K (Aquamephyton) Use for prophylaxis to treat hemorrhagic disease of the newborn. Side effects: Hyperbilirubinuria Eye prophylaxis (Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1% ( not already used causes chemical conjunctivitis) Prophylactic measure to protect against Neisseria gonorrhoeae and Chlamydia trachomatis Side effects: Silver nitrate can cause chemical conjuctivitis Impaired gas exchange related to immature pulmonary functioning Risk for fluid volume deficit related to insensible water loss at birth and small stomach capacity Risk for aspiration related to weak or absent gag reflex a nd/or administration of tube feedings

Bedside equipment

Drug study




Nursing diagnosis

1. 2. 3.



Nursing intervention

Hypothermia related to lack of subcutaneous and brown fat deposits, inadequate shiver response, immature thermoregulation center, large body surface area in relation to body weight, and/or lack of flexion of extremities toward the body. 5. Risk for infection related to immature immune response, stasis of respiratory secretions, and/ or aspiration 6. Imbalanced nutrition: less than body requirements related to lack of energy to suck and/or weak or absent sucking reflex. ( Mosbys Comprehensive Review of Nursing for NCLEX-RN page 216) The nurses first priority in preparing a safe environment for a preterm newborn with low Apgar scores is to prepare respiratory resuscitation equipment. Airway maintenance is the first priority. Give the mother oxygen by mask during the birth to provide the preterm infant with optimal oxygen saturation at birth ( 85-90%). Keeping maternal analgesia and anesthesia to a minimum also offers the infant the best chance of initiating effective respiration. Bedside larngyoscope, endotracheal tube, suction catethers and synthetic surfactant to be administered by the endotracheal tube. Infant must be kept warm during resuscitation procedures so he or she is not expending extra energy to increase the metabolic rate to maintain body temperature. Observe for changes in respirations, color and vital signs Check efficacy of Isolette: maintain heat, humidity and oxygen concentration, administer oxygen only if necessary Maintain aseptic technique to prevent infection Adhere to the techniques of gavage feeding for safety of infant Observe weight-gain patterns Determine blood gases frequently to prevent acidosis. Institute phototherapy when hyperbilirubinemia occurs Support parents by letting them verbalize and ask questions to relieve anxiety. Provide liberal visiting hours for parents, allow them to participate in care. Arrange follow-up before and after discharge by a visiting nurse. (Mosbys Comprehensive Review of Nursing for NCLEX-RN page 216)



Figure 28

Definition P Contributing factors O S T T E R M I N F A N T A Classic signs Low socioeconomic level Poor nutritional status Lack of pre natal care Multiparous mothers Cigarette smoking The age of the mother (the highest incidence is in mothers younger than age 20.) Mothers with diabetes mellitus Congenital abnormalities such as omphalocele. Body is covered with lanugo Old man facies

Intrauterine weight loss, dehydrations and chronic hypoxia old man faces Long & thin with cracked skin which is loose, wrinkled and strained greenish yellow, with no vernix nor lanugo Long nails with firm skull Wide eyed alertness of one month old baby

Maternal & child nursing; a developmental approach to comprehensive cgfns and nclex review; 5th ed. Page 131 Abnormal laboratory values

Screening test Inc

Inc De


Best procedure So

Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own.

Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn. To establish clear airway. Intubations NOTE: head of the infant in neutral position with towel under shoulder. Best position Complications Po NOTE: Post mature neonates have difficulty maintaining glucose reserves. Other common problems include Meconium aspiration syndrome, polycythemia, congenital anomalies, seizure activity and cold stress. NOTE: The infant who are exposed to high blood-glucose levels in utero may experience rapid and profound hypoglycemia after birth because of the cessation of a high in-utero glucose load. The small-for-gestational-age infant has use up glycogen stores as a result of intrauterine malnutrition and has blunted hepatic enzymatic response with which to carry out gluconeogenesis. NOTE: The patient with post-term pregnancy is at high risk for decreased placental functioning, therefore increasing the risk of inadequate oxygen circulation to the fetus Bedside equipment Drug study E Su Eye prophylaxis (Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1% Prophylactic measure to protect against Neisseria 1. Vitamin K (Aquamephyton) Use for prophylaxis to treat hemorrhagic disease of the newborn Side effects: Hyperbilirubinuria

Meconium aspiration syndrome Respiratory distress syndrome


gonorrhoeae and Chlamydia trachomatis Side effects: Silver nitrate can cause chemical conjuctivitis Nursing diagnoses 1. Ineffective airway breathing 2. Risk for fluid volume deficit related to insensible water loss at birth 3. Ineffective infant feeding pattern 1. Assess newborns respiratory rate, depth and rhythm. Auscultate lung sound. Note: Meconium stained syndrome of POST MATURE neonates Aspiration of meconium is best prevented by suctioning the neonates nasopharynx immediatelt after the head is delivered and before the shoulders and chest are delivered. As long as the chest is compressed in the vagina, the infant will not inhale and aspirate meconium in the upper respiratory tract. Meconium aspiration blocks the air flow to the alveoli, leading to potentially life threatening respiratory complications. 2. 3. Anticipate the infants need to be breastfeed Demonstrate technique for feeding to mother, note proper positioning of the infant, latching on technique, rate of delivery of feeding and frequency of burping Provide a relaxed environment during feeding Adjust frequency and amount of feeding according to infants response Alternate feeding procedure (nipple and gavage feeding) according to infants ability. Administer IV fluids after birth to provide Glucose to prevent hypoglycemia, monitor closely the infusion rate. Kept the infant under a radiant heat warmer to preserve energy Monitor babys weight, serum electrolytes and ensure adequate fluid intake Measure urine output by weighing diapers Check for blood stools to evaluate for possible bleeding from intestinal tract. Keep a restful environment. Suction every 2 hours or more often as necessary Position newborn on side or back with the neck slightly extended Administer O2, anticipate the need for CPAP or PEEP Continue to assess the newborns respiratory status closely. Encourage as much parental participation in the newborns care as condition allows

Nursing interventions


Monitor mothers effort, provide feedback and assistance as needed Suggest mother to monitor infants weight periodically

OTHER NEW BORN ABNORMALiTIES A. RESPIRATORY DISTRESS SYNDROME - Delay in lung maturation and deficiency in surfactant - Common among cesarean birth and low birth weight - A serious lung disease immaturity and inability to pre-resulting in hypoxia and acidosis NOTE: More common in neonates delivered by cesarean section than in those delivered vaginally.

COMMON SIGNS Cyanosis, dyspnea, sternal and/or costal retractions, tachypnea, grunting, and nasal flaring, flaring nares, Expiratory grunting MANAGEMENT Maintain a patent airway, place the infant in a warm isollete with oxygen, administer antibiotics as prescribed and correct acidosis

B. HEMOLYTIC DISEASE - ABO or Rh incompatibility COMMON SIGNS - Jaundice in 24 hours of life, signs of anemia (restlessness, fatigue, anorexia) enlargement of liver and spleen and increase in bilirubin levels PREVENTION INDIRECT COOMBS TEST - Tests for anti-Rh (+) Ab in mothers circulation - Performed during pregnancy at first visit & again about 28 weeks gestation RESULTS: - If (-) at 28 weeks, a small dose of (MicroRhogam) is given prophylactically to prevent sensitization in the 3rd trimester. - Rhogam may also be given after 2nd trimester amniocentesis - If (+), levels are titrated to determine potential effects on the fetus DIRECT COOMBS TEST - Tests done on the cord blood at delivery to determine presence of (+) Ab on fetal RBCs RESULTS - If both indirect & direct Coombs test is NEGATIVE & infant is Rh (+) - NEGATIVE: No formation of Anti-Rh (+) Ab - Rhogam (Rho [D] human immune globulin is given to the Rh (-) mother to prevent development of anti-Rh (+) Ab as the rest of sensitization from present/just terminated pregnancy.


C. HYPERBILIRUBINEMIA - Serum bilirubin greater than 15 mg/dl within first 24-36 hours of life are alarming - At any serum bilirubin level, jaundice during the first day of pathological process Evaluation is indicated when serum: over 12 mg/dL in the term newborn Therapy is aimed at preventing results in permanent neurological damaging from the deposition of bilirubin in cells TREATMENT:


The goal of phototherapy is to decrease the serum unconjugated bilirubin level because a high level may lead to bilirubin encephalopathy (kernicterus). Phototherapy doesn't prevent hypothermia or promote respiratory stability. It has no effect on conjugated bilirubin, a water-soluble substance easily excreted in urine and stool. Phototherapy increases gastric motility, causing the infant to have many green, watery stools. The increased gastric motility also causes the infant to be irritable. There is no evidence that the newborn has a lactose intolerance or malabsorption problem, nor is there evidence that the newborn's bilirubin levels are rising to dangerous levels. NOTE: The phototherapy lights must be turned off when serum bilirubin levels are drawn because the light decreases the bilirubin levels in the test tube, and the result reported wouldnt be accurate. The infant should be repositionec at least every 2 hours to permit the light to reach all skin surfaces. The infants intake should be increased to compensate for the fluid loss through the skin and the loose stools. The eye patches are removed with every feeding, and the eyes are assessed for conjunctivitis every 8 hours.

NURSING IMPLEMENTATION: Expose as much of the newborn's skin as possible Cover the genital area, and monitor genital area for skin irritation or breakdown ( priapism may occur) Cover the newborn's eyes with eye shields or patches; make sure eyelids are closed when shields or patches are applied Remove the shields or patches at least once per shift to inspect the eyes for infection or irritation and to allow eye contact . Measure the quantity of light every 8 hours Monitor skin temperature closely Increase fluids to compensate for water loss Expect loose green stools and green urine Monitor the newborn's skin color with the florescent light turned off, every 4 to 8 hours


Monitor the skin for bronze baby syndrome, a grayish brown discoloration of the Reposition newborn every 2 hours

ERYTHROBLASTOSIS FETALIS Rh antigens from the baby's blood enter the maternal bloodstream Destruction of RBCs those results from an antigen antibody reaction Exchange of fetal and maternal blood takes place primarily when the placenta separates at birth The mother produces anti-Rh antibodies against the fetal blood cells


Antibodies are harmless to the mother but attach to the erythrocytes in the fetus and cause hemolysis Sensitization is rare with the first pregnancy ABO incompatibility is usually less severe

B. Assessment 1. hyperbilirubinemia & hemolytic anemia 2. Jaundice that develops rapidly after birth and before 24 hours (PATHOLOGICAL JAUNDICE) C. Implementation 1. 2. Administer Rho(D) immune globulin to the mother during the first 72 hours after delivery if the Rhnegative mother delivers an Rh-positive fetus but remains unsensitized The baby's blood is replaced with Rh-negative blood to stop the destruction of the baby's red blood cells; the Rh-negative blood is replaced with the baby's own blood gradually NOTE: The RH negative mother who has no titer (negative Coombs test results, non sensitized) and who has delivered an RH positive fetus is given an intra muscular injection of anti-RH (D) (RHoGAM). Paternal blood type might be determined for the pregnant RH negative woman in order to help determine fetal blood type.. RHoGAM blocks antibody production by attaching to fetal RH positive blood cells in the maternal circulation before an immunological response is initiated. RHoGAM must be administered to unsensitized postpartum women after the birth of each RH positive infant to prevent production of antibodies. If the father of future fetuses is RH positive heterozygous, there is a 50% chance of an RH negative infant; if he is RH positive homozygous, all infants will be RH positive.


NOTED FEATURES: Short palpebral fissures, Hypoplastic philtrum, short, upturnednose, Flat midface Thin upper lip, Low nasal bridge, Abnormal palmar creases, Respiratory distress [apnea, cyanosis), Congenital heart disorders, Irritability, hypersensitivity to stimuli, Tremors Poor feeding, Seizures. NOTE: These are signs of Heroine withdrawal usually occurs within 24 to 48 hours of birth. The newborn may be jittery and hyperactive. The cry is often shrill and persistent with yawning and sneezing. Tendon reflexes are increased, and Moros reflex is decreased. NOTE: Heroin withdrawal neonates High pitch cry, increase ICP, hypoglycemia, loud and lusty cry NURSING INTERVENTION: 1. Monitor for respiratory distress 2. Position newborn on side to facilitate drainage of secretions


3. Keep resuscitation equipment at the bedside 4. Monitor for hypoglycemia 5. Assess suck and swallow reflex 6. Administer small feedings and burp well 7. Suction as necessary 8. Monitor I & 0 9. Monitor weight and head circumference (Check for Increase ICP) 10. Decrease environmental stimuli 11. The use of narcotic antagonists to reverse respiratory depression in the drug addicted neonate is contraindicated because these drugs may precipitate acute withdrawal in the neonate.

NEW BORN OF DIABETIC MOTHER A. Description Neonate born to an insulin-dependent mother or gestational diabetic mother and with high incidence of congenital anomalies. COMPLICATIONS: High incidences of hypoglycemia, respiratory distress, hypocalcemia, and hyperbilirubinemia B. Assessment MACROSOMIA & LGA as a result of excess fat and glycogen in tissues Edema or puffiness in the face and cheeks Signs of hypoglycemia, such as twitching, difficulty in feeding, lethargy, apnea, seizures, and cyanosis Hyperbilirubinemia Signs of respiratory distress, such as tachypnea, cyanosis, retractions, grunting, and nasal flaring

NOTE FOR CHARACTERISTICS OF HYPOGLYCEMIA: Abnormally low level of glucose (less than 30 mg/dL in the first 72 hour 45 mg/dL after the first 3 days of life N 2. Normal blood glucose level is 40 to a 1-day-old neonate and 50 to 90 neonate older than 1 day Increased respiratory rate Twitching, nervousness, or tremors Unstable temperature Cyanosis NURSING INTERVENTION: 1. Monitor for signs of respiratory distress 2. Monitor bilirubin and blood glucose levels 3. Monitor weight 4. Feed early, with 10% glucose in water, breast milk, or formula as prescribed 5. Administer IV glucose to treat necessary and as prescribed 6. Monitor for edema 7. Monitor for tremors & seizures SMALL FOR GESTATIONAL AGE A. Description: A neonate who is plotted at or below the 1Oth percentile on the intrauterine growth curve NOTE: #1 Predisposing factor is Maternal Smoking


B. Assessment 1. Fetal distress 2. Gestational age and physical maturity 3. Lowered or elevated body temperature 4. Physical abnormalities 5. Hypoglycemia 6. Signs of polycythemia: a. Ruddy appearance b. Cyanosis c. Jaundice 7. Signs of infection 8. Signs of aspiration of meconium NOTE: Obtaining a blood sample to determine glucose level would have the highest priority to on SGA. A common complication of the SGA newborn immediately after birth is hypoglycemia because of the increased metabolic rate in response to heat loss and poor hepatic glycogen stores. The SGA newborn may also have suffered intrauterine hypoxia, which depletes glucose. C. Implementation 1. Maintain airway 2. Maintain body temperature 3. Observe for signs of respiratory distress 4. Monitor for infection and initiate measures to prevent sepsis 5. Monitor blood glucose levels and for signs of hypoglycemia 6. Initiate early feedings and monitor for signs of aspiration 7. Provide stimulation, such as touch and cuddling

A. NERVOUS SYSTEM ANOMALIES - Myelomeningocele type of spina bifida, in which the spinal cord and associated membranes protrude through a gap in the laminae of the vertebrae.

SPINA BIFIDA Synonyms Definition Types Spinal Dysraphia Refers to malformation of spine in which the posterior portion of the laminae of the vertebrae fails to close. Spina bifida occulta Meningocele Myelomeningocele

Meningocele Myelomening



( meningom yelocele)
Spina bifida occulta




severe form of spina bifida .( p. 898, Textbook of Basic Nursing Lippincott 6th ed.)One of the meninges (the Spinal cord covering) protrudes or herniated through opening in vertebral column. (p. 898, Textbook of Basic Nursing Lippincott 6th ed.) Protrusio n of the spinal cord protrudes through the back. Sacs are covered by thin membrane & nerve are exposed Neurologi cal deficits are evident Meninges or protective covering around the spinal cord has pushed out through the opening in the vertebrae in a sac. Spinal cord intact Neurologi cal deficit are usually NOT PRESENT Can be


Nursing Diagnosis and Interventio n

Impaired skin Integrity related to impaired motor & sensory function. Risk for Infection related to contamination Nursing Interventions: Protecting the skin integrity 1. Avoid positioning on the infant's back to prevent pressure on the sac. 2. Do not place any covering directly over the sac. 3. Observe sac for evidence of irritation or leakage of CSF 4. Use prone position w/ hips slightly flexed to decrease tension on the sac. 5. Place a foam rubber pad/ small pillow or roll diaper between the infants legs to maintain hips in abduction & to prevent or counteract subluxation. 6. Provide skin care especially ankles, knees, tip of nose, cheeks & chin. 7. Provide passive range of motion exercise. 8. Use foam or fleece pad to reduce pressure of the mattress against the skin. 9. Avoid touching the sac. Preventing Infection 1. Keep area clean from urine and feces 2. Keep the infant clean esp. buttocks & genitalia 3. Apply sterile gauze /moistened towel and watch for any signs of infection.( fever, irritability, lethargy, oozing of fluid or pus from the sac)

Note: Same w/ Meningcele


. .