Handouts Obstetric Nursing

Maternal and Child Nursing

THE FEMALE REPRODUCTIVE SYSTEM

I.

External Genitalia a. Mons pubis b. Labia majora  Nulliparous:  multiparous:

c. Labia minora d. Clitoris  Sensitive to touch & temperature  2 erectile tissue: corpus cavernosa  Sexual intercourse:  Clitoral congestion & erection  Produce cheese-like secretion:

e. Vestibule a. b. c. d. e. II.

Internal Genitalia a. Vagina  8-12 cm long  Before puberty  After puberty

b. Uterus  Organ of:  Layers:  Parts:  2.5-3 inches long  2 inches wide  50-70 gms  Supporting ligaments:

1. Broad 2. Round 3. Posterior c. Fallopian Tube Parts:  Interstitial  Isthmus  Ampulla  Infundibulum

d. Ovaries 6-19 gms, 1.5-3cm wide, 2-5 cm long 1

Maria Nazarethe A. Sulit| ©2009


III.

Accessory Structures a. Mammary glands S-

W-

D-

 Parts: o

Acini cells

o

Lactiferous duct

o

Lactiferous sinus 

Dilated portion behind the nipple



Reservoir of milk

o

Nipples

o

Areola 

Montgomery tubercles

 Hormones o

Estrogen 

o

Progesterone 

o

o

Stimulates the dev’t of acinar structures of the breast

Human Placental Lactogen 

o

Stimulates dev’t of the ductile structures of the breast

Promotes breast dev’t during pregnancy

Prolactin 

Stimulates milk production



inhibited by estrogen

Oxytocin 

Let down reflex



inhibited by progesterone

THE MALE REPRODUCTIVE SYSTEM

I.

External Genitalia a. Penis b. Scrotum

II. Internal Genitalia a. Testes  Descends in the scrotum at 28 week gestation  4-5 cm long  Parts o

Seminiferous tubules 

o

Leydig’s/ interstitial cells 

o

where spermatogenesis takes place Found around the semineferous tubules

Sertoli cells

b. Epididymis  Appx 20 feet long  Passageway for the traveling sperm for 12-20 days

2



c. Vas deferens  Passageway of the sperm from the epdidymis in the testes to the urethra

d. Ejaculatory duct The Process of Spermatogenesis Testes 

epididymis 

Vas Deferens 

Seminal Vesicle (secreted: fructose form of glucose, nutritative value) 

Ejaculatory Duct 

Prostate Gland

Cowpers Gland 

Urethra

III. Accessory structures a. Seminal vesicles b. Prostate gland c. Bulbourethral gland The Analogous Male

Female

Spermatozoa Glans clitoris Scrotum Vagina Testes Fallopian tube Prostate gland Bartholin’s gland 3



THE EVOLUTION OF LIFE

I.

Prefertilization a. Ovum moves to the ampulla by means of peristaltic movement b. Sperm moves into the ampulla by means of their tail c. Before sperm can penetrate the ovum, the cap must be removed Capacitation- physiologic removal of the acrosome d. Acrosome reactionHyaluronidase- proteolytic enzyme released Zona pellucid-protective covering of the ovum Corona radiate-cells that encircle the zona pellucida

II.

Conception/Fertilization Zona reaction- ovum becomes impenetrable to other sperms

 Zygote  Blastomere  Morula  Blastocyst  Embryo  Fetus

III.

Implantation

 Trophoblast o

Placenta    

o

Fetal membrane

o

Umbilical cord

o

Amniotic fluid

 Embryoblast o

Germ Layers 

Ectoderm



mucus membrane, acessories, nervous system



Entoderm



bladder, GIT, tonsils, thyroid gland, respiratory system



Mesoderm



kidneys, musculoskeletal, reproductive, cardiovascular cardiovascular

 Embryonic Membrane

a. Chorion - Outer membrane b. Amnion - Inner membrane c. Amniotic fluid  Slightly yellow

d. Placenta  Contains 30 separate (cotyledons)

4



2 Functions: a. Metabolic exchange  produces nutrients needed by the embryo  systhesis of glycogen, cholesterol & fatty acids

b. Endocrine Function  HCG  HPL o

Human chorionic somatomammotropin somatomammotropin

o

Promotes normal nutrition & growth of the fetus

 Estrogen  Progesterone

e. Umbilical cord IV.

Fetal Development 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months

ANTEPARTUM

I.

Schedule of Visits

II.

Classification of Pregnancy

 Gravida  Para  TPALM

III.

Determination of Pregnancy

 Presumptive Sign o

Amenorrhea

o

Breast changes

o

Skin changes

o

Quickening

o

Chadwick’s Sign

 Probable Sign

5

o

Goodell

o

Hegar

o

Piskacek



 Positive Sign o o o

IV.

Physiologic Changes of Pregnancy a.Breast a.Breast  Increase in size & nodularity  Enlarged Montgomery’s tubercles  Veins become prominent  Colostrum

b. Uterus  Increase in vascularity  Presence of Hegar’s sign

c.Cervix c. Cervix  Formation of mucus plug or operculum  Presence of Goodell’s sign

d. Vagina e. Gastrointestinal system  Constipation  Heartburn  Hemorrhoids  Morning sickiness

f. Urinary system g.Musculoskeletal g. Musculoskeletal system h. Intergumentary system  Chloasma  Linea nigra  Striae gravidarum

i. Endocrine system  Increase activity & hormone production

V.

Antepartum Assessment a. Nagele’s Rule

b. Fundal Height

6



c. Leopold’s Maneuver    

VI.

Evaluation of Fetal Well Being  Fundic Souffle o

Caused by blood rushing through the umbilical arteries. Synchronous with the FHR.

 Uterine Souffle o

Caused by the sound of blood passing through the uterine vessels. Synchronous with the maternal pulse.

 Amniocentesis o

TEST RESULTS: within 2-4 weeks

o

Complication: Premature labor, Infection, Rh isoimmunization

 Electronic Fetal Heart Rate Monitoring

a. NST o

Tocodynamometer records fetal movements and Doppler ultrasound measures fetal heart rate to assess fetal well-being well- being after 28 weeks.

o

2 or more FHR accelerations of 15 seconds over a 20 minute interval, and return of FHR to normal baseline.

b. Contraction Stress Test o

Late decelerations with at least 50% of contractions

o

No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in 10 minute period.

 Fetal Activity

VII.

o

Daily recording of fetal movements

o

3 or more movements felt in 1 hour

Psychosocial Adaptation to Pregnancy st

a. 1 Trimester o

nd

b. 2

o

acceptance of the biological fact of pregnancy Trimester acceptance of the fetus as a distinct individual and a person to care for

rd

c. 3 Trimester o

prepare realistically for the birth and parenting of the child

INTRAPARTUM

I.

Theories of Labor a. Uterine Stretch Theory b. Oxytocin Theory c. Progesterone Deprivation Theory d. Prostaglandin Theory e. Theory of the Aging Placenta 7



II.

Factors Affecting Labor A. Passageway o

Diagonal Conjugate- from lower border of symphysis pubis to sacral promontory

o

Obstetric conjugate- distance between inner surface of symphysis pubis & sacral promontory

o

True conjugate or conjugate vera

o

Tuber-ischial diameter/ Intertuberous diameter- measures the outlet between the inner borders of ischial tuberosities

 Pelvic Divisions o

False

o

True- Consists of the pelvic inlet, pelvic cavity, and pelvic outlet

o

Linea Terminalis

 Types of Pelvis  Android  Anthropoid  Gynecoid  Platypelloid

8



B. Passenger a. Fetal Attitude b. Fetal Presentation c. Fetal Lie d. Fetal Positions C. Power- refers to the frequency, duration, and strength of uterine contractions to cause complete cervical effacement and dilation D. Placental factors E. Psyche III.

Premonitory Signs of Labor

a. Lightening b. Cervical changes  Effacement  Dilation

c. Regular Braxton Hick’s Contraction d. Rupture of amniotic membrane e. Nestling behaviors f. IV.

Weight loss True vs False Labor True Labor

False Labor Regular contractions

Decrease in frequency & intensity Shorter intervals bet. contractions Activity such as walking either has no effect or decreases contraction

Activity such as walking, increases contractions

Disappear while sleeping

No appreciable change in the cervix V.

Labor Contractions

VI.

Fetal Monitoring

 Variability o

Irregular fluctuations in the baseline of FHR of 2 cycles per minute or gre ater

 Accelerations o

9

15 bpm rise above baseline followed by a return to baseline Maria Nazarethe A. Sulit| ©2009


 Decelerationso

Fall below baseline lasting 15 seconds or more followed by a return to baseline a. Type 1

  

b. Type 2   

c. Type 3   

VII.

Labor a. Stage 1 Latent

Active

Transition

Time

Cervix

Contraction

Intensity

Manifestations

b. Stage 2  Cardinal Movement of Labor (Even Donna Failed In Easy English Exam)

c. Stage 3

10



d. Stage 4

VIII.

APGAR A P G A R

POSTPARTUM

I.

Uterine involution

II.

Lochia a. Rubra b. Serosa c. Alba

III.

Post Partum Psychosocial Adaptation a. Taking In b. Taking Hold c. Letting Go

TERATOGENS

– any drug or irradiation, the exposure to which may cause damage to the fetus

a. Streptomycin/Anti – Streptomycin/Anti – TB – TB – b. Tetracycline c. Vitamin K – K – d. Iodides – Iodides – e. Thalidomides – Thalidomides – f.

Steroids – Steroids –

g. Lithium – Lithium – Substances

11

Effects to Fetus

a. Alcohol

LBW

b. Cigarette

LBW

c. Caffeine

LBW

d. Cocaine

LBW



TORCH – TORCH – group of infections that can cross the placenta or ascend through the birth canal and adversely affect fetal growth

TORCHANTEPARTUM COMPLICATIONS

I.

Ectopic Pregnancy Causes: a. b. c. Assessment Findings: Complications:  Hemorrhage/shock  Peritonitis

Diagnostics:  Culdocentesis  Ultrasound

Management: II.

Abortion

12



Causes: a. b. c. Assessment Findings:

Management:

III.

Hydatidiform Mole Types: a. Complete b. Partial Assessment Findings:

Management: IV.

Incompetent Cervix Assessment Findings: Management:

V.

Hyperemesis Gravidarum

VI.

Anemia

VII.

Placenta Previa Perdisposong Factors:      

Assessment Findings:

13



VIII.

Abruptio Placenta Risk Factors:  Uterine anomalies  Multiparity  Trauma to the abdomen rd

 Previous 3

trimester bleeding

 Abnormally large placenta

Types:   


CHARACTERISTCS

ABRUPTIO PLACENTA

Onset

3 Trimester

3 Trimester

Shock

Moderate to severe

Usually not present

Delivery

Immediate delivery, usually

rd

PLACENTA PREVIA rd

Bleeding Pain & Uterine Tenderness FHR Presenting Part

by CS 14


Delivery maybe delayed,


IX.

Pregnancy Induced Hypertension Incidence:  Severe nutritional deficiencies  < 15 years or > 35 years of age     

Common Types:  Gestational HTN

 Preeclampsia

 Eclampsia

15



Assessment Findings: a) Mild Pre-Eclampsia  Increase systole > 30 mmhg (3 measurements)  Increase diastolic 15 mmhg

b) Severe Pre-Eclampsia  >160/110 mmhg or higher (2 occasions)  Proteinuria 3-4+

c) Eclampsia  Presence of convulsions  Coma

Management:

 Hydralazie (Apresoline)  Magnesium sulfate  Magnesium sulfate  Diazepam  Phenobarbital  Phenytoin

16



X.

Gestational Diabetes Mellitus


Diagnostics:  FBS  HbA 1cv  Oral Glucose Tolerance Test

Management:

XI.

RH Incompatibility

Management:  Blood test early pregnancy 

17



XII.

Multiple Gestation Types:  Monozygotic Twins

 Dizygotic Twins

Assessment Findings:  Uterine size is greater than expected  Palpation of three or more large parts  Different FHT

Complications:  Fetal malpresentation  Uterine dysfunction due to over stretching  Twin to twin transfusion

Management:  Prenatal care  Balanced diet  Rest periods  Anticipatory guidance & support

INTRAPARTUM COMPLICATIONS

I.

Premature Rupture of Membranes Amniotic fluid gushing from the vagina in the absence of contraction Contributing Factors:  Amniotic sac with weak structure  Recent sexual intercourse

Diagnostics:  Nitrazine test tape

Management:  Monitored : infection / spontaneous labor  Bed rest

 Tocolytic therapy  Betamethasone (Celestone)

II. Cord Prolapse 18



Etiology:  Rupture of membranes with the fetal presenting part unengaged  Hydramios

Assessment Findings:  Cord protruding from the vagina  Cord palpated in the vagina or cervix  Fetal distress

Management:  O2 therapy  Push presenting part forward  Deliver ASAP

III. Preterm Labor Etiology:  Incompetent cervix  Placenta previa/Abruptio placenta  Previous preterm labor

Management:  Tocolytic therapy not needed if contractions stops  Fetal and uterine contraction monitoring

 Ritodrine HCl (Yutopar)  Terbutaline sulfate (Brethine)  Magnesium Sulfate  NSAIDS  Indomethacin (Indocin)  Betamethasone

IV. Post Term Labor Assessment Findings:  Weight loss and decreased uterine size

Management:  Provide emotional and physical support

V. Induction of Labor a. Amniotomy - Initiated when the cervix is soft, partially effaced, slightly dilated,

presenting part is engaged b. Prostaglandin 19



- 8-12 hours after Prostaglandin E2 administration, pump infusion of

Oxytocin (Pitocin) c. Oxytocin

 Dinoprostone (Prepidil)  Prostin E2 suppository or gel  OXYTOCIN (Pitocin, Syntocinon)

VI. Precipitate Labor Complications: a. mother b. infant Management: - Support and guide fetal head through birth canal when birth occurs

VII. Uterine Rupture Causes:  Rupture of the scar from a previous CS 

Forceps delivery



Use of oxytocin



Fundal push

Management:  IVF  maintain patent airway

VIII.

20

Episiotomy



Assessment Findings: REEDA-

Management: 

Apply ice packs to perineal area for the first first 12-24 hours after delivery.



Sitz bath with either warm or cool water

IX. Lacerations st

 1 Degree nd

Degree

rd

Degree

th

Degree

 2  3  4

X. Forceps Delivery Purpose:  Prevents excessive pounding of the fetal head against the perineum  Prevents exhaustion from a woman’s pushing effect

Assessment Findings:  Cervix fully dilated before use of forceps  Fetus in vertex presentation  Bowel and bladder empty

XI. Cesarean Section

21



Types: a. Classical Advantage  Simple and rapid to perform 

Disadvantage  Potential for rupture of the scar with subsequent pregnancy 

b. Pfannenstiel’s incision Advantages  Less chance of rupture of uterine scar during future deliveries  Fewer postpartum complications

Disadvantages  Longer to perform than classic incision

XII. Uterine Inversion Types: a.Forced a.Forced Inversion Cause : excessive pulling of the cord , vigorous manual expression of the placenta or clots from an atonic uterus b. Spontaneous Inversion Cause: due to increased abdominal pressure from bearing down, coughing, or sudden abdominal muscle contraction Predisposing Factors:  Straining after delivery of the placenta  Vigorous kneading of the fundus to expel the placenta  Manual separation and extraction of the placenta

Assessment Findings:  Extrusion of the inner uterine lining into the vagina

Management:  Restore the uterus to its normal position  use of general anesthesia and tocolytic therapy

POSTPARTUM COMPLICATIONS

I.

Post Partum Hemorrhage

Management:  Monitor BP and PR Q5-15 minutes  Prepared for a possible D&C  IV infusion, oxytocin, and BT

22



 Oxytoxic methylergonovine maleate (Methergine) (Methergine)

II.

Subinvolution Delayed return of the enlarged uterus to normal size and function Assessment Findings:  Larger than normal uterus  Prolonged lochial discharge

Management:  Massage uterus, facilitate voiding  Administer prescribed medications

III.

Puerperal Infection

IV.

Mastitis Inflammation of the breast tissue caused by infection or stasis of milk in the ducts Management:  Administer antibiotics  Breast feed frequently

V.

Post Partum Mood Disorders  Postpartum Blues  Postpartum Depression  Postpartum Psychosis

FAMILY PLANNING

Natural Method  



Abstinence Coitus interruptus (withdrawal) (withdrawal) 80% effective with typical use Rhythm (Calendar method) Ovulation occurs 14 days (plus or minus 2 days) prior to next menses sperm viable for 5 days ovum is capable of being fertilized for 24 hours fertile period = period = shortest cycle minus 18 days and longest cycle minus 11 days 91% effective with perfect use; 75% effective with typical use 23





Basal body temperature (BBT) Temperature drops just prior to ovulation, rises and fluctuates at higher level until 2-4 days prior to next menses basal thermometer – thermometer – shows tenths of a degree get temperature each AM prior to getting out of bed avoid intercourse on the day temperature drops and for 3 days thereafter 97% effective with perfect use; 75% effective with typical use



Cervical Mucus method (Billing’s, Ovulation) Luteal Phase - infertile period - dominant hormone: progesterone characteristics:dry - vaginal characteristics:dry characteristics: - cervical mucus characteristics:  scant  cloudy, white to yellow  beading – beading – on microscope Follicular phase – phase – ovulation - fertile period - dominant hormone: estrogen - vaginal characteristics: wet characteristics: - cervical mucus characteristics:  profuse, clear  thin, watery, slippery  stretchable (spinnbarkheit (spinnbarkheit )  ferning – ferning – on microscope assess cervical mucus daily avoid intercourse when cervical mucus is first noted to become more clear, stretchable and slippery and for about 4 days effectiveness the same as basal body temperature



Symptothermal Method o Ovulation o Menstrual calendar o Effectiveness: 98% (perfect use), 75% (typical use) 24



Mechanical Methods





Male condom Latex, plastic or natural membranes effectiveness: 97% (perfect use); 86% (typical use)



Female condom Thin polyurethane sheath with flexible rings at each end Cover the cervix, lines the vagina and partially shields the perineum May be inserted up to 8 hours before intercourse Effectiveness: 95% (perfect use); 79% (typical use)



Spermicides Kill spermatozoa before it reaches cervix Make vaginal pH strongly acidic Helps prevent STDs Active ingredient: nonoxynol Forms: a. contraceptive foam b. creams and jellies c. spermicidal vaginal tablet d. spermicidal condom e. film allergic reaction is possible must be applied with each act of intercourse onset of action varies Diaphragm Circular rubber disc fitted over cervix to prevent entrance of sperm cells into uterus Of different sizes Fitted by an obstetrician during: a. first time of use b. after every delivery/abortion c. weight loss of at least 10lbs largest size that fits is chosen inspect for tears and holes by holding against the light can be inserted 2 hours before intercourse but left f or 6 hours after intercourse do not leave more than 24 hours complication: toxic shock syndrome a. elevation of temperature b. diarrhea and vomiting c. weakness and faintness d. muscle aches e. sore throat f. sunburn type rash effectiveness: 94% (perfect use), 80% (typical use)

25





Cervical Cap Resembles a diaphragm but smaller with taller dome Insert at least 20 minutes but no longer than 4 hours prior to intercourse May be left in place for 48 hours

Hormonal Methods 

Contraceptive Pills Consist of estrogen and progesterone inhibit ovulation by suppressing FSH and LH cause thickening of cervical mucus alter motility of fallopian tubes 2 types of packets: a. 21 day pill – pill – rest day of 7 days b. 28 day pill – pill – last 7 pills either iron supplement or lactose Forms of OCP a. Combination Oral Contraceptives Contraceptives - contain both an estrogen and a progestin - formulations: 1. monophasic  contains fixed amount estrogen and progestin  e.g.: cyproterone/ethinylestradiol, Desogestrel/ethinylestradiol 2. biphasic  fixed or variable amount of estrogen nd  progestin increases in the 2 half of the cycle  e.g.: desogestrel/Ethinyldestradiol  7 tabs 25 mcg progestin/40mcg estrogen  15 tabs 125mcg progestin/30mcg estrogen 3. Triphasic  amount of estrogen may be fixed or variable while amount of progestin increases in 3 equal phases  e.g., Levonorgestrel/Ethinyldes Levonorgestrel/Ethinyldestradiol tradiol  6 tabs 30 mcg progestin/50mcg estrogen  5 tabs 40 mcg progestin/75mcg estrogen  10 tabs 30mcg progestin/75mcg estrogen - effectiveness: 99.1% (perfect use), 95% (typical use) b. progestin-only pills (POPs) - “mini“mini-pills” - contain low doses of progestins - considered in women seeking a highly effective, reversible and coitally independent independent method of contraception - action: a. prevents ovulation b. thickens cervical mucus and suppresses the endometrium - effectiveness with perfect use: 95.5% - with typical use: 95%

26



- warning signs and symptoms (ACHES) A – abdominal pain C – chest pain,cough H – headache, dizziness



Norplant (Subdermal Implant)

a. b.

six silastic capsules containing progestin implanted subdermally upper inner arm first 7 days of menstrual cycle action:

prevent ovulation stimulate production of thick cervical mucus



Long Acting Progestin Injections medroxyprogesterone acetate acetate (Depo-Provera) 150mg IM I M every 3 months st starting with 1 5-7 days of the menstrual cycle blocks LH surge action: a. suppress ovulation b. thickens cervical mucus - effectiveness: 97.7%



Combination transdermal contraceptive patch Norelgestromin/ethinylestradiol 150mcg/20mcg per 24 hr patch apply 1 patch weekly x 3 weeks followed by 1 week patch free period. Women >90kg may find patch less effective Patch applied to clean, dry, hair-free skin on: buttock, abdomen, upper outer arm or upper torso Avoid irritated or broken skin, breasts or skin in contact with tight clothing/cosmetic



INTRAUTERINE DEVICE Contraception achieved by immobilizing sperm and impeding travel from cervix to fallopian tube Types: a. Progesterone T (progestasert)  for women allergic to copper b. Copper T380A (ParaGard)  for women with at least 1 child  can be left in place x 10 years

c.

Levonorgestrel  Suited for women with heavy menstruation st

 Inserted in uterus during 1 7 days of menstrual cycle  Effective x 5 years

27



- warning signs & symptoms (PAINS) P – period late, abnormal spotting A – abdominal pain, pain with intercourse I – Infection exposure abnormal Discharges N – not feeling well, fever S – string missing Surgical Methods a. b.

28

vasectomy tubal ligation


Handouts Obstetric Nursing

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