Stages of Fetal Growth and Development 3-4 days travel of zygote – mitotic cell division begins *Pre-embryonic Stage a. ZygoteZygote - fertilized ovum. Lifespan of zygote – from fertilization to 2 months b. Morula – mulberry-like ball with 16 – 50 cells, 4 days free floating & multiplication c. Blastocyst – enlarging cells that forms a cavity that later becomes the embryo. Blastocyst – covering of blastocys that later becomes placenta & trophoblast d. Implantation/ NidationNidation - occurs after fertilization 7 – 10 days. Fetus- 2 months to birth. birth . placenta previa – implantation at low side of uterus Signs of implantation: 1. slight pain 2. slight vaginal spotting - if with fertilization – corpus luteum continues luteum continues to function & become source of estrogen & progesterone while progesterone while placenta is not developed. 3 processes of Implantation 1. Apposition-act of bringing together 2. Adhesion-act of being adhered or united 3. Invasion-act or instance of invading or entering as enemy. Dicidua – thickened endometrium ( Latin – falling off) * Basalis (base) part of endometrium located under fetus where placenta is delivered * Capsularies – encapsulate the fetus * Vera – remaining portion of endometrium. th
Chorionic Villi- 10 Villi- 10 – 11 day, finger life projections 3 vessels= A – unoxygenated blood V – O2 blood A – unoxygenated blood Wharton’s jelly – protects cord Chorionic villi sampling (CVS) – removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes. E. Cytotrophoblast – inner layer or langhans layer – protects fetus against syphilis 24 wks/6 months – life span of langhans layer increase. Before 24 weeks critical, might get infected syphilis F. Synsitiotrophoblast – synsitial layer – responsible production of hormone 1. Amnion – inner most layer a. Umbilical CordCord - FUNIS, whitish grey, 15 – 55cm, 20 – 21”. Short cord: abruptio placenta or inverted uterus. Long cord:cord coil or cord prolapse b. Amniotic Fluid – bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline. *Function of Amniotic Fluid: 1. cushions fetus against sudden blows or trauma 2. facilitates musculo-skeletal development 3. maintains temp 4. prevent cord compression 5. help in delivery process ****normal amount of amniotic fluid – 500 to 1000cc polyhydramnios, hydramnioshydramnios - GIT malformation TEF/TEA, increased amt of fluid oligohydramnios- decrease amt of fluid – kidney disease Diagnostic Tests for Amniotic Fluid 1
A. Amniocentesis empty bladder before performing the procedure. Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for: st 1. Genetic screening- maternal serum serum alpha feto-protein test (MSAFP) – 1 trimester 2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity – rd 3 trimester Testing time – 36 weeks decreased MSAFP= MSAFP= down syndrome increase MSAFP = MSAFP = spina bifida or open neural tube defect *Common complication of amniocenthesis – infection *Dangerous complications – spontaneous abortion rd 3 trimester- pre term labor Important factor to consider for amniocentesis- needle insertion site Aspiration of yellowish amniotic fluid – jaundice – jaundice baby baby Greenish – meconium – meconium Amnioscopy – direct visualization or exam to an intact fetal membrane. A. Amnioscopy B. Fern Test - determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid) C. Nitrazine Paper Test – – diff amniotic fluid & urine. Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn f luid. 1. Chorion – where placenta is developed Lecithin Sphingomyelin L/S Ratio- 2:1 signifies fetal lung maturity not capable for RDS Shake test – – amniotic + saline & shake Foam test Phosphatiglyceroli: PG+ definitive test to determine fetal l ung maturity
a.Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis. Size: 500g or ½ kg -1 inch thick & 8” diameter Functions of Placenta: 1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion 2. GIT – transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. I f mom hypoglycemic, fetus hypoglycemic System- artery - carries waste products. Liver of mom detoxifies fetus. 3. Excretory System4. Circulating system – achieved by selective osmosis 5. Endocrine System – produces hormones
Human Chorionic Gonadrophin – maintains corpus luteum alive. Human placental Lactogen or sommamommamotropin sommamommamotropin Hormone – for mammary gland development. Has a diabetogenic effect – serves as insulin antagonist Relaxin Hormone- causes softening joints & bones estrogen progestin
6. It serves as a protective barrier against some microorganisms – HIV,HBV Fetal Stage “ Fetal Growth and Development” 2
Entire pregnancy days – 266 – 280 days 37 – 42 weeks Differentiation of Primary Germ layers * Endoderm st 1 week endoderm – primary germ layer Thyroid – for basal metabolism Parathyroid - for calcium Thymus – development of immunity Liver – lining of upper RT & GIT * Mesoderm – development of heart, musculoskeletal system, kidneys and repro organ * Ectoderm – development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth First trimester: st 1 month Brain & heart development GIT& resp Tract – remains as single tube 1. Fetal heart tone begins – heart is the oldest part of the body 2. CNS develops – dizziness of mom due to hypoglycemic effect Food of brain – glucose complex CHO – pregnant womans food (potato) Second Month 1. All vital organs formed, placenta developed nd 2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2 month 3. Sex organ formed 4. Meconium is formed Third Month 1. Kidneys functional 2. Buds of milk teeth appear 3. Fetal heart tone heard – Doppler – 10 – 12 weeks 4. Sex is distinguishable Second Trimester: FOCUS Trimester: FOCUS – length of fetus Fourth Month 1. lanugo begins to appear 2. fetal heart tone heard fetoscope fetoscope,, 18 – 20 weeks 3. buds of permanent teeth appear
1. 2. 3. 4. 5.
Fifth Month lanugo covers body actively swallows swallows amniotic fluid 19 – 25 cm fetus, st Quickening- 1 fetal movement. 18- 20 weeks primi, 16- 18 wks – multi fetal heart tone heard heard with or without instrument instrument
Sixth Month 1. eyelids open 2. wrinkled skin 3. vernix caseosa present Third trimester: Period of most rapid growth. FOCUS: weight of fetus Seventh Month – development of surfactant – lecithin Eighth Month 1. lanugo begin to disappear 2. sub Q fats deposit 3
3. Nails extend to fingers Ninth Month 1. lanugo & vernix caseosa completely disappear 2. Amniotic fluid decreases Tenth Month – bone ossification of fetal skull
Terratogens- any Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus A. Drugs: th Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8 cranial nerve – poor hearing & deafness Tetracycline – staining tooth enamel, inhibit growth of long bone Vitamin K – hemolysis (destroy of RBC), hyperbilirubenia or jaundice Iodides – enlargement of thyroid or goiter Thalidomides – Amelia or pocomelia, absence of extremities
B. C. D. E.
Steroids – cleft lip or palate Lithium – congenital malformation Alcohol – lowered weight (vasoconstriction (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by microcephaly Smoking – low birth rate Caffeine – low birth rate Cocaine – low birth rate, abruption placenta
TORCH (Terratogenic) Infections – viruses CHARACTERISTICS: CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus.
T – toxoplasmosis toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat O – others. others. Hepa A or infectious heap – oral/ fecal (hand washing) Hepa B, HIV – blood & body fluids Syphilis st R – rubella rubella – German measles – congenital heart disease (1 month) normal rubella titer 1:10 <1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’t get pregnant for 3 months. months. Vaccine is terratogenic C – cytomegalo cytomegalo virus H – herpes herpes simplex virus II.
Physiological Adaptation of the Mother to Pregnancy
A. Systemic Changes 1. Cardiovascular System – increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc of blood - easy fatigability, increase heart workload, workload, slight hypertrophy hypertrophy of ventricles, epistaxis – due to hyperemia of nasal membrane membrane palpitation, palpitation, Physiologic Anemia – pseudo anemia of pregnant women
Normal Values Hct 32 – 42% Hgb 10.5 – 14g/dL 4
Criteria st rd 1 and 3 trimester.- pathologic anemia if lower HCT should not be 33%, Hgb should not be < 11g/dL nd
2 trimester – Hct should not <32% Hgb Shdn't < 10.5% pathologic anemia anemia if lower Pathogenic Anemia iron deficiency anemiais anemiais the most common hematological disorder. It affects toughly 20% of pregnant women. - Assessment reveals: Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia
Nursing Care: Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetable -alugbati,saluyot, malunggay, horseradish, ampalaya Parenteral Iron ( Imferon) – severe anemia, give I M, Z tract- if improperly administered, hematoma. Oral Iron supplements (ferrous sulfate sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs after, black stool, constipation Monitor for hemorrhage
Alert:
Iron from red meats is better absorbed iron form other sources Iron is Iron is better absorbed when taken with foods high in Vit C such C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs
Edema – lower extremities due venous return is constricted due to large belly, elevate legs above hip level. Varicosities – pressure of uterus use support stockings, avoid wearing knee high socks use elastic bandage – lower to upper -
Vulbar varicositiesvaricosities - painful, pressure on gravid uterus, to relieve - position – side lying with pillow under hips or modified knee chest position Thrombophlebitis – presence of thrombus at inflamed blood vessel pregnant mom hyperfibrinogenemia increase fibrinogen increase clotting factor thrombus formation candidate outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens Mgt: 1.) 2.) 3.) 4.) 5.) 6.)
Bed rest Never massage Assess + Homan sign once only might dislodge thrombus Give anticoagulant to prevent additional clotting (thrombolytics will dilute) Monitor APTT antidote for Heparin toxicity, protamine sulfate Avoid aspirin! Might aggravate bleeding. 5
2. Respiratory system – common problem SOB due to enlarged uterus & increase O2 demand Position- lateral expansion of lungs or side lying position. st
Gastrointestinal – 1 trimester change 3. Gastrointestinal
Morning Sickness – nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon - small freq feeding. Vomiting in preg – emesisgravida. Metabolic alkalosis, F&E imbalance – primary med mgt – replace fluids. Monitor I&O
constipation – progesterone resp for constipation. Increase fluid intake, increase fiber diet - fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha. Except guava – has pectin that’s constipating – veg – petchy, malungay. - exercise -mineral oil – excretion of fat soluble vitamins * Flatulence – avoid gas forming food – cabbage * Heartburn – or pyrosis – reflux of stomach content to esophagus - small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical increase salivation – ptyalsim – mgt mouthwash *Hemorrhoids – pressure of gravid uterus. Mgt; hot sitz bath for comfort st
rd
4. Urinary System – frequency during 1 & 3 trimester lateral expansion of lungs or side l ying pos – mgt for nocturia Acetyace test – albumin in urine Benedicts test – sugar in urine 5. Musculoskeletal Lordosis – pride of pregnancy Waddling Gait – awkward walking due to relaxation rel axation – causes softening of joints & bones Prone to accidental falls – wear low heeled shoes Leg Cramps – causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 imbalance(#1 cause while pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus Mgt: Increase Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis Dilis,, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab. Vit D for increased Ca absorption dorsiflexion B. Local Changes Local change: Vagina: V – Chadwick’s – Chadwick’s sign – blue violet discoloration of vagina C – Goodel's Goodel's sign – change of consistency of cervix I – Hegar's Hegar's – change of consistency of isthmus (lower uterine segment) LEUKORRHEA – whitish gray, mousy odor discharge ESTROGEN – hormone, resp for leucorrhea OPERCULUM – mucus plug to seal out bacteria. PROGESTERONE – hormone responsible for operculum PREGNANT – acidic to alkaline change to protect bacterial growth (vaginitis)
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Problems Related to the Change of Vaginal Environment: a. Vaginitits – trichomonas vaginalis due to alkaline environment of vagina of pregnant mom Flagellated protozoa – wants alkaline S&Sx: S&Sx: Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema Mgt: st Carcinogenic drug so don’t give at 1 trimester FLAGYL – (metronidazole – antiprotozoa). Carcinogenic 1. treat dad also to prevent reinfection 2. no alcohol – has antibuse effect VAGINAL DOUCHE – IQ H2O : 1 tbsp white vinegar candidiasis due to candida albecans, fungal infection. b. Moniliasis or candidiasis due Color – white cheese like patches adheres to walls of vagina. Signs & Symptoms: Management – antifungal – Nistatin, genshan violet, cotrimaxole, canesten Gonorrhea -Thick purulent discharge Vaginal warts- condifoma acuminata due to papilloma virus Mgt: cauterization 2. Abdominal Changes – striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue – avoid scratching, use coconut oil, umbilicus is protruding
3. Skin Changes – brown pigmentation nose chin, cheeks – chloasma melasma due melasma due to increased melanocytes. Brown pinkish line- linea nigranigra- symphisis pubis to umbilicus 4. Breast Changes – increase hormones, color of areola & nipple rd pre colostrums present by 6 weeks, colostrums at 3 trimester Breast self examexam - 7 days after mens –– supine with pillow at back quadrant B – upper outer – common site of cancer Test to determine breast cancer: 1. mammography – 35 to 49 yrs once every 1 to 2 yrs 50 yrs and above – 1 x a yr 6. Ovaries – rested during pregnancy 7. Signs & symptoms of Pregnancy A. Presumptive – s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . Subjective B. Probable – signs observed by the members of health team. Objective C. Positive Signs – undeniable signs confirmed by the use of instrument. Ballotment sign of myoma * + HCG – sign of H mole - trans vaginal ultrasound. Empty bladder - ultrasound – full bladder placental grading – rating/grade o – immature 1 – slightly mature 2 – moderately mature 3 – placental maturity What is deposited in placenta which signify maturity - there is calcium 7
Presumptive Breast changes Urinary freq Fatigue Amenorrhea Morning sickness Enlarged uterus Cloasma Linea negra Increased skin pigmentation Striae gravidarium Quickening
Probable Goodel'sGoodel's- change of consistency of cervix Chadwick’s- blue violet discoloration of vagina Hegar'sHegar's- change of consistency of isthmus Elevated BBT – due to increased progesterone Positive HCG or HCG or (+)preg test Ballottement Ballottement – bouncing of fetus when lower uterine is tapped sharply Enlarged abdomen Braxton Hicks contractions – painless irregular contractions
Positive Ultrasound evidence (sonogram) full bladder Fetal heart tone Fetal movement Fetal outline Fetal parts palpable
III. Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory) First Trimester: Trimester : No tanginal signs & sx, surprise, ambivalence, denial – sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy Focus: bodily changes of preg, nutrition Second Trimester – tangible S&Sx. mom identifies fetus as a separate entity – due to presence of quickening, fantasy. Developmental task – accept growing fetus as baby to be nurtured. Health teaching: growth & development of fetus. Third Trimester: Trimester : - mom has personal identification on appearance of baby Development task: prepare of birth & parenting of child. HT: responsible parenthood ‘baby’s Layette” – best time to do shopping. Most common fear – let mom listen to FHT to allay fear Lamaze classes
VII. Pre-Natal Visit: V isit: 1. Frequency of Visit:
st
1 7 months – 1x a month 8 – 9 months – 2 x a month 10 – once a week post term 2 x a week 2. Personal data – name, age (high risk < 18 &>35 yrs old) record to determine high risk – HBMR. Home base mom’s record. Sex ( pseudocyesis or false pregnancy on men & women) Couvade syndrome – dad experiences what mom goes through – lihi) Address, civil status, religion, culture & beliefs with respect, non judgmental Occupation – financial condition or occupational hazards, education background background – level knowledge 3. Diagnosis of Pregnancy th 100 day . 60 – 70 day peak HCG. 6 weeks after LMPLMP - best to 1.) urine exam to detect HCG at 40 – 100 get urine exam. – test for preg detects beta subunit of HCG as early as 7 – 10days 2.) Elisa test – – do it yourself 3.) Home preg kit – st 4. Baseline Data: V/S esp. BP, monitor wt. (increase wt – 1 1 sign preeclampsia) Weight Monitoring First Trimester: Normal Weight gain 1.5 – 3 lbs Second trimester: normal weight gain 10 – 12 lbs Third trimester: normal weight gain 10 – 12 lbs Minimum wt gain – 20 – 25 lbs Optimal wt gain – 25 – 35 lbs
(.5 – 1lb/month) (4 lbs/month) (1 lb/wk) (4 lbs/ month) ( 1lb/wk)
5. Obstetrical Data: 8
nullipara – no pregnancy Gravida- # of pregnancy a. GravidaPara - # of viable pregnancy b. Para Viability – the ability of the f etus to live outside the uterus at the earliest possible gestational age. age of viability - 20 – 24 wks Term -37 – 42 42 wks, wks, Preterm -20 Preterm -20 – 37 weeks abortion <20 weeks Sample Cases: 1 – abortion GTPAL nd 1 – 2 mo 2 0 01 0 G – 2 P – 0 th
1 – 40 AOG GT P A L th 1 – 36 AOG 612 2 4 2 – misc 1 – twins 35 AOG th 1 – 4 month G6 P3 th
1 – 39 week 1 – miscarriage 1 – stillbirth 33 AOG (considered as para) rd 1 – preg 3 wk
GP GTPAL 4 2 4 11 1 1
1 – 33 P st 1 41 L 1 – abort A 1 – still 39 GP GTPAL 1 triplet 32 6 4 6 2 2 15 th 1 4 mon c. Important Estimates: 1. Nagele’s Rule – use to determine expected date of delivery Get LMP -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar M D Y +9 +7 no year LMP Jan 25, 04 +9 +7 10 / 32 / 04 - 1 add 1 month to month 11/31/04 EDD 2. McDonald’s Rule – to determine age of gestation IN WEEKS FUNDIC HT X 7/8=AOG in WK Fundic Ht X 7 = AOG in weeks 8 Fr sypmhisis pubis to fundus 24 X 7 =21 wks 8 Bartholomew’s Rule – to determine age of gestation by 3. Bartholomew’s gestation by proper location of fundus at abdominal cavity. 3 months – above sym pub 5 months – level of umbilicus 9 months – below zyphoid 10 months – level of 8 months due to lightening 9
4. Haases rule – to determine length of the fetus in cm. cm . st Formula: 1 ½ of preg , square @ month nd 2 ½ of preg, x @ month by 5 3mos x 3 = 9cm st 4 mos x 4 = 16 cm 10 x 5 = 50 cm 1 ½ of preg 5 x 5 = 25 cm 6 x 5 = 30 cm 7 x 5 = 35 cm 8 x 5 = 40 cm 9 x 5 = 45 cm
nd
2 ½ of preg
d. tetanus immunizations – prevents tetanus neonatum -mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3 TT1 – any time during pregnancy TT2 – 4 wks after TT1 – 3 yrs protection TT3 – 6 months after TT2 – 5 yrs protection TT4 – 1 yr after TT3 – 10 yrs protection TT5 – yr after TT4 – lifetime protection 5. Physical Examination: A. Examine teeth: sign of infection Danger signs of Pregnancy C - chills/ fever fever - infection Cerebral disturbances ( headache – preeclampsia) A – abdominal pain ( pain ( epigastric pain – aura of impending convulsions B – boardlike abdomen – abruption placenta Increase BP – HPN Blurred vision – preeclampsia st nd Bleeding – 1 trimester, abortion, ectopic pre/2 – H mole, incompetent cervix rd 3 – placental anomalies S – sudden gush of fluid – PROM (premature rupture of membrane) prone to inf. E – edema to upper ext. ext . (preeclampsia) (preeclampsia) 6. Pelvic Examination – internal exam 1. empty bladder 2. universal precaution EXT OS of cervix – site for getting specimen Site for cervical cancer Pap Smear – cervical cancer - composed of squamous columnar tissue Result: Class I I - normal Class IIA – acytology but no evidence of malignancy B – suggestive of infl. Class III – cytology suggestive of malignancy Class IV – cytology strongly suggestive of malignancy Class V – cytology conclusive of malignancy Stages of Cervical Cancer Stage 0 – carcinoma insitu 10
1 – cancer confined to cervix 2 - cancer extends extends to vagina 3 – pelvis metastasis 4 – affection to bladder & rectum 7. Leopold’s Maneuver Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone - use palm! Warm palm.
Prep mom: 1. Empty bladder 2. Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles) Procedure: st 1 maneuver: maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part to determine presentation nd
2 Maneuver: with Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound) where nd the bell of the stethoscope is placed to determine FHT. Get V/S(before 2 maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé. Uterine soufflé – maternal H rate rd
3 Maneuver: Maneuver: using the right hand, grasp the symphis pubis pubis part using thumb and fingers. To determine degree of engagement. Assess whether the presenting part is engaged in the pelvis )Alert : if the head i s engaged it will not be movable). th
4 Maneuver: the Examiner changes the position by facing the patient’s feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude – relationship of fetus to 1 another. When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head will be flexed and vertex presenting. Attitude – relationship of fetus to a part – or degree of flexion Full flexion – when the chin touches the chest 8.Assessment of Fetal Well-BeingA. Daily Fetal Movement Counting (DFMC) –begin 27 weeks Mom- begin after meal - breakfast a. Cardiff count to 10 method – one method currently available (1) Begin at the same time each day (usually in the morning, after breakfast) breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs) (2) Expected findings – 10 movements in 1 hour or less 3) Warning signs a.) more then 1 hour to reach 10 movements b.) less then 10 movements in 12 hours(non-reactive- fetal distress) c.) longer time to reach 10 FMs than on previous days d.) movement are becoming weaker, less vigorous Movement alarm signals - < 3 FMs in 12 hours 4.) warning signs should be reported to healthcare provider immediately; often require further testing. Examples: nonstress test (NST), biographical profile (BPP) B. Nonstress test – to determine the response of the fetal heart rate to activity Indication – pregnancies at risk for placental insufficiency Postmaturity 11
a.) pregnancy induced hypertension (PIH), diabetes b.) warning signs noted during DFMC c.) maternal history of smoking, inadequate nutrition Procedure: Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor); external monitor is applied to document fetal activity; mother activates the “mark button” on the electronic monitor monitor when she feels fetal movement. Attach external noninvasive fetal monitors tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) 1. tocotransducer over transducer over abdominal site where most distinct fetal heart sounds are detected 2. ultrasound transducer over 3. monitor until at least 2 FMs are detected in 20 minutes if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen if no FM after 1 hour further testing may be indicated, such as a CST
Result: Noncreative Nonstress Not Good Reactive Responsive is Real Good
i.
Interpretation of results reactive result 1. Baseline FHR between 120 and 160 beats per minute 2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least least 15 seconds in a 10 to 20 minute period as a result of FM 3. Good variability – normal irregularity of cardiac cardiac rhythm representing representing a balanced interaction interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip. 4. result indicates a healthy fetus with an intact nervous system
ii. Nonreactive result 1. Stated criteria for a reactive result are not met 2. Could be indicative of a compromised fetus. Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST) 9. Health teachings a. Nutrition – do nutritional assessment – daily food intake High risk moms: 1. Pregnant teenagers – low compliance to heath regimen. 2. Extremes in wt – underweight, over wt – candidate for HPN, DM 3. Low socio – economic status 4. Vegetarian mom – decrease CHON – needs Vit B12 – cyanocobalamin cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation. (Decrease folic acid – spina bifida/open neural tube defect) How many Kcal CHO x4,CHON x4, fats x 9
Recommended Nutrient Requirement that increases During Pregnancy Nutrients Requirements Food Source Calories 300 calories/day above the Caloric increase should reflect - Foods of high nutrient value such Essential to supply energy for prepregnancy daily requirement - increased metabolic rate to maintain ideal body weight as protein, complex - utilization of nutrients and meet energy requirement carbohydrates (whole grains, 12
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protein sparing so it can be used for Growth of fetus Development of structures required for pregnancy including placenta, amniotic fluid, and tissue growth.
Protein Essential for: - Fetal tissue growth - Maternal tissue growth including uterus and breasts - Development of essential pregnancy structures - Formation of red blood cells and plasma proteins * Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH) Calcium-Phosphorous Essential for Growth and development of fetal skeleton and tooth buds Maintenance of mineralization of maternal bones and teeth Current research is : Demonstrating an association between adequate calcium intake and the prevention of pregnancy induce hypertension Iron Essential for - Expansion of blood volume and red blood cells formation - Establishment of fetal iron stores for first few months of life
to activity level - Begin increase in second trimester - Use weight – gain pattern as an indication of adequacy of calorie intake. - Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage.
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vegetables, fruits) Variety of foods representing foods sources for the nutrients requiring during pregnancy No more than 30% fat
60 mg/day or mg/day or an increase of 10% Protein increase should reflect - Lean meat, poultry, fish above daily above daily requirements for - Eggs, cheese, milk age group - Dried beans, lentils, nuts - Whole grains Adolescents have a higher protein requirement than * vegetarians must take note of the mature women since amino acid content of CHON foods adolescents must supply protein consumed to ensure ingestion of for their own growth as well as sufficient quantities of all amino acids protein t meet the pregnancy requirement
Calcium increases of - 1200 mg/day representing mg/day representing an increase of 50% 50% above above prepregnancy daily requirement. - 1600 mg/day is recommended for the adolescent. 10 mcg/day of mcg/day of vitamin D is D is required since it enhances absorption of both calcium and phosphorous
Calcium increases should reflect: - dairy products : milk, yogurt, ice cream, cheese, egg yolk - whole grains, tofu - green leafy vegetables - canned salmon & sardines w/ bones - Ca fortified foods such as orange juice - Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood
30 mg/day representing mg/day representing a doubling of the pregnant daily requirement - Begin supplementation at 30- mg/day in second trimester, since diet alone is unable to meet pregnancy requirement - 60 – 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin values prior to pregnancy or who have iron deficiency anemia. - 70 mg/day of vitamin C
Iron increases should reflect liver, red meat, fish, poultry, eggs enriched, whole grain cereals and breads dark green leafy vegetables, legumes nuts, dried fruits vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage, potatoes iron from food sources is more readily absorbed when served with foods high in vit C 13
Zinc Essential for * the formation of enzymes * maybe important in the prevention of congenital malformation of the fetus. Folic Acid, Folacin, Folate Essential for formation of red blood cells and prevention of anemia DNA synthesis and cell formation; may play a role in the prevention of neutral tube defects (spina bifida), abortion, abruption placenta Additional Requirements Minerals iodine Magnesium Selenium Vitamins E Thiamine Riborlavin Pyridoxine ( B6) B12 Niacin
which enhances iron absorption - inadequate iron intake results in maternal effects – anemia depletion of iron stores, decreased energy and appetite, cardiac stress especially labor labor and birth - fetal effects decreased availability of oxygen thereby affecting fetal growth * iron deficiency anemia is anemia is the most common nutritional disorder of pregnancy. 15mcg/day representing 15mcg/day representing an increase of 3 mg/day over prepreganant daily requirements.
400 mcg/day representing mcg/day representing an increase of more then 2 times the daily prepregnant requirement. 300mcg/day supplement for women with low folate levels or dietary deficiency 4 servings of grains/day
175 mcg/day 320 mg/day 65 mcg/day
10 mg/day 1.5 mg/day 1.6 mg/day 2.2 mg/day 2.2 mg day 17 mg/day
Zinc increases should reflect liver, meats shell fish eggs, milk, cheese whole grains, legumes, nuts Increases should reflect liver, kidney, lean beef, veal dark green leafy vegetables, broccoli, legumes. Whole grains, peanuts
Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy. Vit stored in body. Taking it not needed – fat soluble vitamins. Hard to excrete.
2.Sexual Activity a.) should be done in moderation b.) should be done in private place c.) mom placed in comfy pos, sidelying or mom on top d.) avoided 6 weeks prior to EDD e.) avoid blowing or air during cunnilingus f.) changes in sexual desire of mom during preg- air embolism Changes in sexual desire: st a.) 1 tri – decrease desire – due to bodily changes nd b.) 2 trimester – increased desire due to increase estrogen that enhances lubrication rd c.) 3 trimester – decreased desire 14
Contraindication in sex: 1. vaginal spotting st trimester – threatened abortion 1 nd 2 trimester – placenta previa 2. incompetent cervix 3. preterm labor 4. premature rupture of membrane 3. Exercise – to strengthen muscles used during delivery process principles of exercise 1.) Done in moderation. moderation. 2.) Must be individualized Walking – best exercise Squatting – strengthen muscles of perineum. Increase circulation to perineum. Squat – feet flat on floor Tailor Sitting – 1 leg in front of other leg ( Indian seat) st
Raise buttocks 1 before head to prevent postural hypotension – dizziness when changing position
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shoulder circling exercise- strengthen chest muscles pelvic rocking/pelvic tilt- exercise – relieves low back pain & maintain good posture * arch back – standing or kneeling. Four extremities on floor
Kegel Exercise – strengthen pulococcygeal muscles - as if hold urine, release 10x or muscle contraction Abdominal Exercise – strengthens muscles of abdominal – done as if blowing candle 4. Childbirth Preparation: Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience. a. Psychophysical 1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery process. Based on imitation of nature. Features: 1.) darkened rm 2.) quiet environment 3.) relaxation tech 4.) closed eye & appearance of sleep 2. Grantly Dick Read Method – fear leads to tension while tension leads to pain b. Psychosexual 1. Kitzinger method – preg, labor & birth & care of newborn is an impt turning pt in woman’s life cycle - flow with contraction than struggle with contraction c. Psychoprophylaxis – prevention of pain Lamaze: Dr. Ferdinand Lamaze 1. Lamaze: req. disciple, conditioning & concentration. Husband is coach Features: 1. Conscious relaxation 2. Cleansing breathe – inhale nose, exhale mouth 3. Effleurage – gentle circular massage over abdominal to relieve pain 4. imaging – sensate focus 15
5. 1.) 2.) 3.) 4.) 5.)
Different Methods of delivery: birthing chair – bed convertible to chair – semifowlers birthing bed – dorsal recumbent pos squatting – relives low back pain during labor pain leboyers – warm, quiet, dark, comfy room. After delivery, baby gets warm bath. Birth under H20 – bathtub – labor & delivery – warm water, soft music.
IX. Intrapartal Notes – inside ER A. Admitting the laboring Mother: Personal Data: name, age, address, etc Baseline Data: v/s esppecially BP, weight Obstetrical Data: gravida # preg, para- viable preg, – 22 – 24 wks Physical Exams,Pelvic Exams B. Basic knowledge in Intrapartum. b. 1 Theories of the Onset of Labor 1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) – contraction action 2.) oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces oxytocin 3.) prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction 4.) progesterone theory – before labor, decrease progesterone will stimulate contractions & labor 5.) theory of aging placenta – life span of placenta pl acenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor). b.2. The 4 P’s of labor 1. Passenger a. Fetal head – is the largest presenting part – common presenting part – ¼ of its length. Bones – 6 bones S – sphenoid F – frontal - sinciput E – ethmoid O – occuputal - occiput T – temporal P – parietal 2 x Measurement fetal head: 1. transverse diameter – 9.25cm biparietal – largest transverse bitemporal 8 cm 2. bimastoid 7cm smallest transverse Sutures – intermembranous spaces that allow molding. 1.) sagittal suture – connects 2 parietal bones ( sagitna) 2.) coronal suture – connect parietal & frontal bone (crown) 3.) lambdoidal suture – connects occipital & parietal bone Moldings: the Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis Fontanels: 1.) Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close 2.) Posterior fontanel or lambda – triangular shape, 1 x 1 cm. Closes – 2 – 3 months. 4.) Anteroposterior diameter suboccipitobregmatic 9.5 cm, complete flexion, smallest AP occipitofrontal 12cm partial flexion occipitomental – 13.5 cm hyper extension submentobragmatic-face submentobragmatic-face presentation 2. Passageway 2. Passageway Mom 1.) < 4’9” tall 16
2.) < 18 years old 3.) Underwent pelvic dislocation Pelvis 4 main pelvic types 1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy 2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow 3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow 4. Platypelloid – flat AP diameter – narrow, transverse – wider b. Pelvis 2 hip bones – 2 innominate bones 3 Parts of 2 Innominate Bones Ileum – lateral side of hips hips - iliac crest – flaring superior border forming prominence of hips Ischium – inferior portion - ischial tuberosity where we sit – landmark to get external measurement of pelvis Pubes – ant portion – symphisis pubis junction between 2 pubis 1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis 1 coccyx – 5 small bones compresses during vaginal de livery
Important Measurements 1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis pubis. Measurement: 11.5 cm - 12.5 cm basis in getting getting true conjugate. (DC – 11.5 cm=true conjugate) 2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm 3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more. Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above. 3. Power –supplied by the fundus of the uterus, are implemented by uterine contractions, a process that causes cervical dilation and then expulsion of the fetus from the uterus the force acting to expel the fetus and placenta – myometrium – powers of labor a. Involuntary Contractions b. Voluntary bearing down efforts c. Characteristics: wave like d. Timing: frequency, duration, intensity 4. Psyche/Person – psychological stress when the mother is fighting the labor experience a. Cultural Interpretation b. Preparation c. Past Experience d. Support System Pre-eminent Signs of Labor S&Sx: - shooting pain radiating to the legs - urinary freq. 1. Lightening – setting of presenting part into pelvic brim - 2 weeks prior to EDD * Engagement- setting of presenting part into pelvic inlet 2. Braxton Hicks Contractions – painless irregular contractions 3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for deli very. Increase epinephrine 17
4. Ripening of the Cervix – butter soft 5. decreased body wt – 1.5 – 3 lbs 6. Bloody Show – pinkish vaginal discharge – blood & leukorrhea 7. Rupture of Membranes – rupture of water. Check FHT Premature Rupture of Membrane ( PROM) - do IE to check for cord prolapse Contraction drop in intensity even though very painful Contraction drop in frequently Uterus tense and/or contracting between contractions Abdominal palpations Nursing Care; Administer Analgesics (Morphine) Attempt manual rotation for ROP or LOP – most common malposition Bear down with contractions contractions Adequate hydration – prepare for CS Sedation as ordered Cesarean delivery may be required, especially if fetal distress is noted Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix into the vagina. Danger signs: PROM Presenting part has not yet engaged Fetal distress Protruding cord form vagina
Nursing care: 1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy. 2. Slip cord away from presenting part 3. Count pulsation of cord for FHT 4. Prep mom for CS Positioning – trendelenberg or knee chest position Emotional support Prepare for Cesarean Section Difference Between True Labor and False Labor False Labor True Labor Irregular contractions Contractions are regular No increase in intensity Increased intensity Pain – confined to abdomen Pain – begins lower back radiates to abdomen Pain – relived by walking Pain – intensified by walking No cervical changes Cervical effacement & dilatation * major sx of true labor. Duration of Labor Primipara – 14 hrs & not more than 20 hrs Multipara – 8 hrs & not > 14 hrs Effacement – softening & thinning of cervix. Use Use % in unit of measurement measurement Dilation – widening of cervix. Unit used is cm. Nursing Interventions in Each Stage of Labor
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2 segments of the uterus 1. upper uterine - fundus fundus 2. lower uterine – isthmus Stage: onset of true contractions to full dilation and effacement of cervix. 1. First Stage: onset Latent Phase: Assessment: Dilations: 0 – 3 cm mom – excited, apprehensive, can can communicate communicate Frequency: every 5 – 10 min Intensity mild Nursing Care: st 1. Encourage walking - shorten 1 stage of labor 2. Encourage to void q 2 – 3 hrs – full bladder inhibit contractions 3. Breathing – chest breathing Active Phase: Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self Frequency q 3-5 min lasting for 30 – 60 seconds Nursing Care: M – edications – have meds ready A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc. D – dry lips – oral care (ointment) dry linens B – abdominal breathing Transitional Phase: intensity: strong Assessment: Dilations 8 – 10 cm Frequency q 2-3 min contractions Durations 45 – 90 seconds
Mom – mood changes with hyperesthesia
Hyperesthesia – increase sensitivity to touch, pain all over Health Teaching Teaching : teach: sacral sacral pressure pressure on lower lower back to inhibit transmission of pain keep informed of progress controlled chest breathing Nursing Care: T – ires I – nform of progress R – estless support her breathing technique E – ncourage and praise D – iscomfort Pelvic Exams Effacement Dilation a. Station – landmark used: ischial spine - 1 station = presenting part 1cm above ischial spine if ( -) floating - 2 station = presenting part 2 cm above ischial spine if (-) floating 0 station = level at ischial spine – engagement + 1 station = below 1 cm ischial spine nd +3 to +5 = crowning – occurs at 2 stage of labor b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother -spine of mom and spine of fetus Two types: b.1. Longitudinal Lie ( Parallel) cephalic Vertex – complete flexion Face Brow Poor Flexion 19
Breech -
Chin Complete Breech – thigh breast on abdomen, breast lie on thigh Incomplete Breech – thigh rest on abdominal Frank – legs extend to head Footling – single, double Kneeling
b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation. c. Position – relationship of the fatal presenting part to specific quadrant of the mother ’s pelvis. Variety: – side of maternal pelvis Occipito – LOA left occipito ant (most common and favorable position) position ) – LOP – left occipito posterior LOP – most common mal position, position, most painful ROP – squatting pos on mom ROT ROA Breech- use sacrum - put stet above umbilicus Shoulder/acromniodorso LADA, LADT, LADP, RADA
LSA – left sacro anterior LST, LSP, RSA, RST, RSP
Chin / Mento LMA, LMT, LMP, RMP, RMA, RMT, RMP Monitoring the Contractions and Fetal heart Tone Spread fingers lightly over fundus – to monitor contractions Parts of contractions: contractions : Increment or crescendo – beginning of contractions until it increases Acme or apex – – height of contraction Decrement or decrescendo – from height of contractions until it decreases Duration – beginning of contractions to end of same contraction Interval – – end of 1 contraction to beginning of next contraction Frequency – – beginning of 1 contraction to beginning of next contraction Intensity - strength of contraction Contraction – vasoconstriction Increase BP, decrease FHT Best time to get BP & FHT just after a contraction or midway of contractions Placental reserve – 60 sec o2 for fetus during contractions Duration of contractions shouldn’t >60 sec Notify MD Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia Health teachings 1.) Ok to shower 2.)NPO – GIT stops function during labor if with food - will cause aspiration 3.)Enema administer during labor a.)To cleanse bowel b.)Prevent infection c.)Sims position/side lying 12 – 18 inch – ht enema tubing Check FHT after adm enema 20
Normal FHT= 120-160 Signs of fetal distress1.) <120 &>160 2.) mecomium stain amnion fluid 3.) fetal thrushing – hyperactive fetus due to lack O2 Stage : fetal stage, complete dilation and effacement to birth. 2. Second Stage: 7 – 8 multi – bring to delivery room 10cm primi – bring to delivery room Lithotomy pos – put legs same time up Bulging of perineum – sure to come out Breathing – panting ( teach mom) nd episiotomy- to prevent laceration, widen vaginal canal, shorten 2 stage of labor. Assist doc in doing episiotomyEpisiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula) Mediolateral – more bleeding & pain, hard to repair, slow to heal -use local or pudendal anesthesia. Ironing the perineum – to prevent laceration Modified Ritgens maneuver – place towel at perineum 1.)To prevent laceration 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord cord if coiled. Pull shoulder down & up. Check time, identification identification of baby. baby. Mechanisms of labor 1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External rotation 7. Expulsion Three parts of Pelvis – 1. Inlet – AP diameter narrow, transverse diameter wider 2. Cavity Two Major Divisions of Pelvis 1. True pelvis – below the pelvic inlet 2. False pelvis – above the pelvic inlet; supports uterus during pregnancy pregnancy
Linea Terminales diagonal Terminales diagonal imaginary line from the sacrum to the symphysis symphysis pubis that divides the false and true pelvis. Nursing Care: To prevent puerperal sepsis - < 48 hours only – vaginal pack Bolus of Ptocin can lead to hypotension.
3. Third Stage: birth to expulsion of Placenta - placental stage placenta has 15 – 28 cotyledons Placenta delivered from 3-10 minutes Signs of placental separation 1. Fundus rises – becomes firm & globular “ Calkins sign ” 2. Lengthening of the cord 3. Sudden gush of blood Types of placental delivery 21
Shultz “shiny” – begins to separate from center to edges presenting the fetal side shiny Dunkan “dirty” – begin to separate form edges edges to center presenting natural side – beefy red or dirty Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. Nsg care for placenta: 4. Check completeness of placenta. 5. Check fundus (if relaxed, massage uterus) 6. Check bp 7. Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives 8. Monitor hpn (or give oxytocin IV) 9. Check perineum for lacerations 10. Assist MD for episiorapy 11. Flat on bed 12. Chills-due dehydration. Blanket, Blanket, give clear liquid-tea, l iquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy. h ours after delivery of placenta – recovery stage. Monitor v/s q 15 for 4. Fourth Stage: the first 1-2 hours f or 1 hr. nd 2 hr q 30 minutes. Check placement of fundus at level of umbilicus. If fundus above umbilicus, deviation of fundus 1.) Empty bladder to prevent uterine atony 2.) Check lochia a. Maternal Observations – body system stabilizes b. Placement of the Fundus c. Lochia d. Perineum – R - edness E- dema E - cchemosis D – ischarges A – approximation of blood loss. Count pad & saturation Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc e. Bonding – interaction between mother and newborn – rooming in types 1.) Straight rooming in baby: 24hrs with mom. 2.) Partial rooming in: baby in morning , at night nursery
Complications of Labor Dystocia – difficult labor related to: Mechanical factor – due to uterine inertia – sluggishness of contraction 1.) hypertonic or primary uterine inertia intense excessive contractions resulting to ineffective pushing MD administer sedative valium,/diazepam – muscle relaxant 2.) hypotonic – secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin. Prolonged labor – normal length of labor in primi 14 – 20 hrs Multi 10 -14 hrs > 14 hrs in multi &> 20 hrs in primi maternal effect – exhaustion. Fetal effect – fetal distress, caput succedaneum or cephal hematoma 22
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nsg care: monitor contractions and FHR
Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding. Earliest sign: tachycardia & restlessness Late sign: hypotension Outstanding Nursing dx: fluid volume deficit Post of mom – modified trendelenberg IV – fast drip due fluid volume def Signs of Hypovolemic Shock: Hypotension Hypo tension Tachycardia Tachy cardia Tachypnea Tachy pnea Cold clammy skin Inversion of the uterus – situation uterus is inside out. MD will push uterus back inside or not hysterectomy. Factors leading to inversion of uterus 1.) short cord 2.) hurrying of placental delivery 3.) ineffective fundal pressure Uterine Rupture Causes: 1.) 1.)Previous classical CS 2.)Large baby 3.) Improper use of oxytocin (IV ( IV drip) drip) Sx: a.) sudden pain b.) profuse bleeding c.) hypovolemic shock d.) TAHBSO Physiologic retraction ring Boundary bet upper/lower uterine segment BANDL’S pathologic ring – suprapubic depression a.) sign of impending uterine rupture Amniotic Fluid Embolism or placental embolism – amniotic fluid or fragments of placenta enters natural circulation resulting to embolism Sx: dyspnea, chest pain & frothy sputum prepare: suctioning end stage: DIC disseminated intravascular coagopathycoagopathy- bleeding to all portions of the body – eyes, nose, etc. Trial Labor – measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor Multi: 8 – 14, primi 14 – 20 Preterm Labor – labor after 20 – 37 weeks) weeks) ( abortion <20 weeks) weeks) Sx: 1. premature contractions q 10 min 2. effacement of 60 – 80% 3. dilation 2-3 cm Home Mgt: 1. complete bed rest 23
2. avoid sex 3. empty bladder 4. drink 3 -4 glasses of water – full bladder inhibits contractions 5. consult MD if symptoms persist Hosp: 1. If cervix is closed 2 – 3 cm, dilation saved by administer administer Tocolytic agents- halts preterm preterm contractions.YUTOPARcontractions.YUTOPAR- Yutopar Y utopar Hcl) 150mg incorporated 500cc Dextrose piggyback. Monitor: FHT > 180 bpm Maternal BP - <90/60 Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IV Tocolytic (Phil) Terbuthaline (Bricanyl or Brethine) – sustained tachycardia Antidote – propranolol or inderal - beta-blocker If cervix is open – MD – steroid dextamethzone (betamethazone) (betamethazone) to facilitate surfactant maturation preventing RDS Preterm-cut cord ASAP to prevent jaundice j aundice or hyperbilirubenia.
th
X. Postpartal Period 5 Period 5 stage of labor after 24hrs :Normal increase WBC WBC up to 30,000 30,000 cumm st
Puerperium – covers 1 6 wks post partum Involution – return of repro organ organ to its non pregnant state. Hyperfibrinogenia - prone to thrombus formation - early ambulation Principles underlying puerperium 1. To return to Normal and Facilitate healing A. Physiologic Changes a.1. Systemic Changes 1. Cardiovascular System - the first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers. 2. Genital tract a. Cervix – cervical opening b. Vaginal and Pelvic Floor th c. Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10 day – no longer palpable due behind symphisis pubis 3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a medium for bacterial growth- (puerperal sepsis)- D&C after, birth pain: 1. position prone 2. cold compress – to prevent bleeding 3. mefenamic acid Lochia-bld, d. Lochia -bld, wbc, deciduas, microorganism. Nsd & Cs with lochia. st 1. Ruba – red 1 3 days present, present, musty/mousy, moderate amt th 2. Serosa – pink to brown 4 – 9 day day,, limited amt 3. Alba – créme white 10 – 21 days very days very decreased amt 24
dysuria - urine collection - alternate warm & cold compress - stimulate bladder 3. Urinary tract: Bladder – freq in urination after delivery- urinary retention with overflow 4. Colon: Constipation – due NPO, fear of bearing down 5. Perineal area – painful – episiotomy site – sims pos, cold compress for immediate pain after 24 hrs, hot sitz bath, not compress sex- when perineum has healed II. Provide Emotional Support – Reva Rubia Psychological Responses: st a. Taking in phase – dependent phase (1 three days) mom – passive, cant make decisions, activity is to tell child birth experiences. Nursing Care: - proper hygiene b. Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions HT: 1.) Care of newborn 2.) Insert family planting method common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite. – let mom cry – therapeutic. c. Letting go – interdependent phase – 7 days & above. Mom - redefines new roles may extend extend until child grows. III. Prevent complications 1. Hemorrhage – bleeding of > 500cc CS – 600 – 800 cc normal NSD 500 cc st
I.
Early postpartum hemorrhage – bleeding within 1 24 hrs. Baggy or relaxed uterus & profuse bleeding – uterine atony. atony. Complications: hypovolemic shock.
Mgt: 1.) 2.) 3.) 4.)
massage uterus until contracted cold compress modified trendelenberg IV fast drip/ oxytocin IV drip
st
1 degree laceration – affects vaginal skin & mucus membrane. nd st 2 degree – 1 degree + muscles of vagina rd nd 3 degree – 2 degree + external sphincter of rectum th rd 4 degree – 3 degree + mucus membrane of rectum
Breast feeding – post pit gland will rel ease oxytocin so uterus will contract. Well contracted uterus + bleeding = laceration assess perineum for laceration degree of laceration mgt episiorapy DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate. bleeding to any part of body hysterectomy if with abruption placenta 25
mgt: BT- cryoprecipitate or fresh frozen plasma Late Postpartum hemorrhage – bleeding after 24 hrs – retained placental fragments II. Mgt: D&C or manual extraction e xtraction of fragments & massaging of uterus. D&C except placenta increta, percreta, Acreta – attached placenta to myometrium. Increta – deeper attachment of placenta to Percreta – invasion of placenta to perimetrium
myometrium
hysterectomy
Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum. too much manipulation large baby pudendal anesthesia Mgt: 1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs 2.) shave 3.) incision on site, scraping & suturing InfectionInfection- sources of infection 1.)endogenous – from within body 2.) exogenous – from outside 1.) anaerobic streptococci – most common - from members health team 2.) unhealthy sexual practices General signs of inflammation: 1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling) 2. purulent discharges 3. fever Gen mgt: 1.) supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity – for antibiotic prolonged use of antibiotic lead to fungal infection inflammation of perineum – see general signs of inflammation 2 to 3 stitches dislocated with purulent discharge Mgt: Removal of sutures & drainage, saline, between & resulting. Endometriosis – inflammation of endometrial lining Sx: Abdominal tenderness, pos. Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic IV. Motivate the use of Family Planning st 1.) determine one’s own beliefs 1 2.) never advice a permanent method of planning 3.) method of choice is an individuals choice. Natural Method – the only method accepted by the Catholic Church Billings / Cervical mucus – test spinnbarkeit & ferning (estrogen) clear, watery, stretchable, elastic – long spinnbarkeit th Basal Body Temperature 13 day temp goes down before ovulation – no sex get before arising in bed LAM – lactation amenorrheal method – hormone that inhibits ovulation is prolactin. breast feeding- menstruation will come out 4 – 6 months bottle fed 2 – 3 months disadvantage of lam – might get pregnant 26
Symptothermal – combination of BBT & cervical. Best method Social Method – 1.) coitus interuptus/ interuptus/ withdrawal - least effective method 2. coitus reservatus – sex without ejaculation – 3. coitus interfemora – “ipit” 4. calendar method OVULATION –count minus 14 days before next mens (14 days before next mens) Origoknause formula – monitor cycle for 1 year -get short test & longest cycle cycle from Jan – Dec shortest – 18 longest – 11 June 26 - 18 8 -
Dec 33 -11 22 unsafe days th
21 day pill- start 5 day of mens st 28day pill- start 1 day of mens missed 1 pill – take 2 next day Physiologic MethodPills – combined oral contraceptives contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to become pregnant- 3 months. Consult OB-6mos. Alerts on Oral Contraceptive: -in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she would wait for at least 3 months before attempting to conceive to provide ti me for the estrogen and progesterone levels to return to normal. - if a new oral contraceptive is prescribed the mother should continue continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses. - discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase incidence incidence of CVA and subarachnoid subarachnoid hemorrhage. Signs of hypertension Immediate Discontinuation Discontinuation A – abdominal pain C – chest pain H - headache E – eye problems S – severe leg cramps If mom HPN – stop pills STAT! Adverse effect: breakthrough bleeding Contraindicated: 1.) chain smoker 2.) extreme obesity 3.) HPN 4.) DM 5.) Thrombophlebitis or problems in clotting factors
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if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again.
DMPA – depoproveda – has progesterone inhibits LH – inhibits ovulation Depomedroxy progesterone acetate – IM q 3 months - never massage injected site, it will shorten duration Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone. 5 yrs – disadvantage if keloid skin as soon as removed – can become pregnant Mechanism and Chemical Barriers
Intrauterine Device (IUD) Action: prevents implantation i mplantation – affects motility of sperm & ovum right time to insert is after delivery or during menstruation primary indication for use of IUD parity or # of children, if 1 kid only don’t use IUD HT: 1.) Check for string daily 2.) Monthly checkup 3.) Regular pap smear Alerts; prevents implantation most common complications: excessive menstrual flow and expulsion of the device (common problem) others: P eriod late (pregnancy suspected) suspected) Abnormal spotting or bleeding A bdominal pain or pain with intercourse I nfection (abnormal vaginal discharge) N ot feeling well, fever, chills S trings lost, shorter or longer Uterine inflammation, uterine perforation, ectopic pregnancy Condom – latex inserted to erected penis or lubricated vagina Adv; gives highest protection against STD – female condom -
Alerts: Disadvantage: it lessen sexual satisfaction it gives higher protection in the prevention of STDs Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSABLE Ht: 1.) 2.) 3.) 4.) 5.)
proper hygiene check for holes before use must stay in place 6 – 8 hrs after sex must be refitted especially if without wt change 15 lbs spermicide – chem. Barrier ex. Foam Foam (most effective), jellies, creams S/effect: Toxic shock syndrome
Alerts: Should be kept kept in place for about 6 – 8 hours 28
Cervical Cap – most durable than diaphragm no need to apply spermicide C/I: abnormal pap smear Foams, Jellies, Creams Surgical Method – BTL , Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects Vasectomy – cut vas deferense. HT: >30 ejaculations before safe sex O – zero sperm count, safe XI. High Risk Pregnancy 1. Hemorrhagic Disorders General Management 1.) CBR 2.) Avoid sex 3.) Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc) 4.) Ultrasound to determine integrity of sac 5.) Signs of Hypovolemic shock 6.) Save discharges – for histopathology – to determine if product of conception has been expelled or not First Trimester Bleeding – abortion or eptopic A. Abortions – termination of pregnancy before age of viability (before 20 weeks) Spontaneous Abortion- miscarriage Cause: 1.) chromosomal alterations 2.) blighted ovum 3.) plasma germ defect Classifications: a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed b. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation) Types: 1.) Complete – all products of conception are expelled. No mgt just emotional support! 2.) Incomplete – Placental and membranes retained. Mgt: D&C Incompetent cervix – abortion McDonalds procedure – temporary circlage on cervix S/E; infection. During delivery, circlage is removed. NSD Sheridan – permanent surgery cervix. CS c. Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. nd Present 2 trimester d. Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty dark brown bleeding Mgt: induced labor with with oxytocin or vacuum vacuum extraction 5.) Induced Abortion – therapeutic abortion to save life of mom. Double effect choose between lesser evil. C. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity. common site: tubal or ampular Dangerous site - interstitial Unruptured Tubal rupture missed period sudden , sharp, severe pain. Unilateral abdominal pain within 3 -5 weeks of missed radiating to shoulder. period (maybe generalized or one sided) shoulder pain (indicative of intraperitoneal bleeding 29
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scant, dark brown, vaginal bleeding
Nursing care: Vital signs Administer IV fluids Monitor for vaginal bleeding Monitor I & O
that extends to diaphragm and phrenic nerve) + Cullen’s Sign – Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding syncope (fainting) Mgt: Surgery depending on side Ovary: oophrectomy Uterus : hysterectomy
Second trimester bleeding C. Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with fertilization. Progressive degeneration of chorionic villi. Recurs. - gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm i s formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly. Use: methotrexate to prevent choriocarcinoma Assessment: Early signs vesicles passed thru the vagina Hyperemesis gravidarium increase HCG Fundal height Vaginal bleeding( scant or profuse) Early in pregnancy High levels of HCG Preeclampsia at about 12 weeks th Late signs hypertension before 20 week Vesicles look like a “ snowstorm” on sonogram Anemia Abdominal cramping Serious complications hyperthyroidism Pulmonary embolus Nursing care: Prepare D&C Do not give oxytoxic drugs Teachings: a. Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma choriocarcinoma b. Avoid pregnancy for at least one year Third Trimester Bleeding “Placenta Anomalies” D. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta. candidate for CS Sx: frank Bright red Painless bleeding Dx: Ultrasound Avoid: sex, IE, enema – may lead to sudden fetal blood loss Double set up: delivery room may be converted to OR Assessment: Engagement (usually has not occurred) Fetal distress Presentation ( usually abnormal) Surgeon – in charge of sign consent, RN as witness 30
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MD explain to patient complication: sudden fetal blood loss Nursing Care NPO Bed rest Prepare to induce labor if cervix is ripe Administer IV
E. Abruptio Placenta – it is the premature separation of the placenta form placenta form the implantation site. It usually u sually occurs after the twentieth week of pregnancy. Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.
F. G. H. I. J. K. L.
Assessment: Concealed bleeding (retroplacental) Couvelaire uterus (caused uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage. Severe abdominal pain Dropping coagulation factor (a potential for DIC) Complications: Sudden fetal blood loss -placenta previa & vasa previa Nursing Care: Infuse IV, prepare to administer blood Type and crossmatch Monitor FHR Insert Foley Measure blood loss; count pads Report s/sx of DIC Monitor v/s for shock Strict I&O Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel may lea d to retained placental fragments if vessel is cut. Placenta Circumvalata – fetal side of placenta covered by chorion Placenta Marginata – fold side of chorion reaches just to the edge of placenta Battledore Placenta – cord inserted marginally rather then centrally Placenta Bipartita – placenta divides into 2 lobes Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta Vasa Previa – velamentous insertion of cord has implanted in cervical OS
2. Hypertensive Disorders (PIH )- HPN after 24 wks of pregnancy, solved 6 weeks post partum. I. Pregnancy Induced Hypertension (PIH)1.) Gestational hypertension - HPN HPN without without edema edema & protenuria protenuria H without without EP 2.) Pre-eclampsia – HPN HPN with edema & protenuria or albuminuria HE P/A 3.) HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count II. Transissional Hypertension – HPN between 20 – 24 weeks III. III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum. Three types of pre-eclampsia 1.) Mild preeclampsia – earliest sign of preeclampsia a.) increase wt due to edema b.) BP 140/90 c.) protenuria +1 - +2 31
2.) Severe preeclampsia Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. convulsion. BP BP 160/110 , protenuria +3 - +4 3.) Eclampsia – with seizure! seizure! Increase BUN – glomerular damage. Provide safety. Cause of preeclampsia st 1.) idiopathic or unknown common in primi due to 1 exposure to chorionic villi 2.) common in multiple pre (twins) increase exposure to chorionic villi 3.) common to mom with low socioeconomic status due to decrease intake of CHON Nursing care: P – romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to urinate. P- prevent convulsions by nursing measures or seizure precaution 1.) dimly lit room . quiet calm environment 2.) minimal handling – planning procedure 3.) avoid jarring bed P- prepare the following at bedside - tongue depressor - turning to side done AFTER seizure! Observe only! for safely. E – ensure high protein intake ( 1g/kg/day) - Na – in moderation A – anti-hypertensive drug Hydralazine ( Apresoline) C – convulsion, prevent – Mg So4 – CNS depressant E – valuate physical parameters for Magnesium sulfate Magnesium SO4 Toxicity: 1. BP decrease 2. Urine output decrease 3. Resp < 12 st 4. Patella reflex absent – 1 sigh Mg SO4 toxicity. antidote – Ca gluconate 3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas) Function: of insulin – facilitates transport of glucose to cell Dx: 1 hr 50gr glucose tolerance test GTT Normal glucose – 80 – 120 mg/dl < 80 – hypoclycemic ( euglycemia) > 120 - hyperglycemia 3 degrees GTT of > 130 mg/dL maternal effect DM st nd rd 1.) Hypo or hyperglycemia – 1 trimester hypo, 2 – 3 trim – hyperglycemic 2.) Frequent infection- moniliasis 3.) Polyhydramnios 4.) Dystocia-difficult birth due to abnormalities in fetus or mom. st rd 5.) Insulin requirement, decrease in insulin by 33% in 1 tri; 50% increase insulin at 2nd – 3 trimester. Post partum decrease 25% due placenta out. Fetal effect 1.) hyper & hypoglycemia 2.) macrosomia – large gestational age – baby delivered > 400g or 4kg 3.) preterm birth to prevent stillbirth Newborn Effect : DM 1.) hyperinsulinism 32
2.) hypoglycemia normal glucose in newborn 45 – 55 mg/dL hypoglycemic < 40 mg/dL Heel stick test – get blood at heel Sx: Hypoglycemia high pitch shrill cry tremors, administer dextrose 3.) hypocalcemia - < 7mg% Sx: Calcemia tetany Trousseau sign Give calcium gluconate if decrease calcium Recommendation Therapeutic abortion If push through through with pregnancy 1.) antibiotic therapy- to prevent sub acute bacterial endocarditis 2.) anticoagulant – heparin doesn’t cross placenta Class I & II- good progress for vaginal delivery Class III & IV- poor prognosis, for vaginal vaginal delivery, not CS! NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver Regional anesthesia! nd Low forcep delivery due to inability to push. It will shorten 2 stage of labor. Heart disease Moms with RHD at childhood Class I – no limit to physical activity Class II – slight limitation of activity. Ordinary activity causes fatigue & discomfort. Recommendation of class I & II 1.) sleep 10 hrs a day 2.) rest 30 minutes & after meal Class III - moderate li mitation of physical activity. Ordinary activity causes discomfort Recommendation: 1.) early hospitalization by 7 months Class IV. marked limitation of physical activity. Even at rest there i s fatigue & discomfort. Recommendation: Therapeutic abortion XII. Intrapartal complications 1. Cesarean Delivery Indications: a. Multiple gestation b. Diabetes c. Active herpes II d. Severe toxemia e. Placenta previa f. Abruptio placenta g. Prolapse of the cord h. CPD primary indication i. Breech presentation j. Transverse lie Procedure: a. classical – vertical insertion. Once classical always classical b. Low segment – bikini line type – aesthetic use VBAC – vaginal birth after CS 33
INFERTILITY INFERTILITY - inability to achieve pregnancy. pregnancy. Within a year of attempting attempting it Manageable STERILITY - irreversible Impotency – inability to have an erection 2 types of infertility 1.) primary – no pregnancy at all st 2.) Secondary – 1 pregnancy, no more next preg st test male 1 more practical & less complicated need: sperm only sterile bottle container ( not plastic has chem.) Sims Huhner test – or post coital test. Procedure: sex 2 hours before test mom – remains supine 15 min after ejaculation Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If >15 – low sperm count Best criteria- sperm motility for impotency Factors: low sperm count 1.) occupation- truck driver 2.) chain smoker administer: clomid ( chomephine citrate) to induce spermatogenesis Mgt: GIFT= Gamete Intra Fallopian Fallopian Transfer for low sperm count count Implant sperm in ampula 1.) Mom: anovulation – no ovulation. Due to increase prolactin – hyperprolactinemia Administer; parlodel ( Bromocryptice Mesylate) Action; antihyper prolactineuria Give mom clomid: action: to induce oogenesis or ovulation S/E: multiple pregnancy 2.) Tubal Occlusion – tubal blockage – Hx of PID that has scarred tubes use of IUD appendicitis (burst) & scarring = dx: hysterosalphingography hysterosalphingography – used to determine tubal patency with use of radiopaque material Mgt: IVF – invitrofertilization (test tube baby) st England 1 test tube baby nd
To shorten 2 stage of labor! 1.) fundal pressure 2.) episiotomy 3.) forcep delivery
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