MATERNAL & CHILD NURSING
Delma P. Latoja MD.,RN.,US-RN
Female Reproductive System
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External Genitalia – collectively called VULVA ( pudenda )
refers to the externally visible structure of the female reproductive system extending from symphysis pubis to the perineum a. Mons Pubis (mons veneris) – fatty pad over the symphysis pubis; cushions & protects pubic bone b. Labia Majora (labium majus) -- longitudinal folds of pigmented skin extending from mons pubis to the perineum; covered with thick, curly hair [ Escutcheon ] c. Labia Minora -- hairless folds of tissue within the labia majora, extending from clitoris to the fourchette d. Clitoris – erectile tissue at the upper end of labia minora Glans - tip of the clitoral body Clitoral Body Prepuce - hood like covering Smegma - epidermal secretion with strong odor e. Vestibule – contains structures: a. Urethral meatus/orifice *Skene’s glands ( paraurethral glands) b. Vaginal introitus *Bartholin’s glands ( vulvovaginal glands ) c. Hymen f. Fourchette -- fold of tissue formed where labia minora meets g. Perineum -- skin-colored muscular area between the vaginal orifice and the anus; *Episiotomy site
Internal Genitalia
a. Vagina -- organ of copulation / “birth canal” hollow, musculomembranous canal (8-12 cm) 4cm diameter Fornix- anterior, posterior and lateral space surrounding the cervix Doderlein’s bacilliFunctions of Vagina: 1. orga organn of copu copula lati tion on
2. Passag Passagee in deliv delivery ery & menstr menstrual ual bloo blood d 3. Secret Secretory ory duct during during mens menstru truati ation on b. Uterus -- “the womb” - pear-shaped, pear-shaped, hollow hollow muscular organ - anteverted, directed forward; 7-8 cm long - functions: Menstruation o Environment for o pregnancy o Labor & delivery La yers rs : - Laye Perimetrium o Myometrium -- middle o layer - “living ligature” - layers of smooth muscle fibers that interlaces=contraction Endometrium o Parts Part s of Uterus Uteru s: a. Corpus – -- uppermost part ( Fundus ) b. Isthmus -
c. Cervix internal os cervical os o external os o - Uterine Ligaments: Broad = 2 winglike o structures that extends from the lateral margin to the uterus to the pelvic walls Round = 2 fibrous cords o from the uterine walls that helps hold the uterus in its forward position Utero-sacral/posterior Utero-sacral/posterior = 2 o cord-like folds of the peritoneum from the lower cervix to the sacrum o *Transverse – Mackenrodt’s Ligaments o
d. Fallopian Tube / Oviducts – salphinges Interstitial o Isthmus o Ampulla – o Infundibulum o - its funnel-shaped opening encircled with FIMBRIAE e. Ovaries – primary sexual organ of female - functions: ovulation o 1
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produce hormones (estrogen & progesterone)
Accessory Structures
a. PELVIS – passageway of fetus Consists of: Innominate bone o - ilium - ischium - pubis sacrum o coccyx o Pelvic Sections/Divisions: False Pelvis -o True Pelvis -o - pelvic inlet – entrance to the true pelvis - midpelvis – mid portion of pelvis - contains ischial spine - pelvic outlet – exit of the the pelvis Pelvic Measurements: Diagonal conjugate -- anterior o sacral promontory to the inferior margin of symphysis pubis (12.5 – 13cm) True conjugate -- from o anterior sacral promontory to the SUPERIOR margin of symphysis pubis (11 – 11.5cm) Obstetric Conjugate -- Sacral o promontory to INNER SURFACE of symphysis pubis (10.5 - 11 cm) Biischial diameter -o distance between ischial spines (10 cm) Tuberischial diameter -o transverse diameter of outlet (8 cm)
b. BREASTS – mammary glands Parts: Acini cells o Collecting duct o Lactiferous sinus o Lactiferous duct o Nipples o Areola – Montgomery’s o tubercles Hormones: o
Prolactin - hormone for milk production
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Oxytocin - hormone for milk expression
Male Reproductive System
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External Genitalia
a. Mons pubis – area over symphysis pubis b. Penis – organ of urination & copulation Shaft Glans penis Prepuce c. Scrotum - wrinkled pouch of thin skin, covering a tight muscle - protects the testes from trauma and changes in temperature - Cremasteric reflex
Internal genitalia
a. Testes - the male sex glands or gonads - 2-3 cm wide that lie in the scrotum Parts: Semineferous tubules - site of o spermatogenesis Leydig’s / interstitial cells - secretes o testosterone Sertoli cells - provide nourishment to the o sperm b. Epididymis-c. Vas deferens d. Ejaculatory duct e. Accessory structures Seminal vesicles o Prostate gland o Bulbourethral gland/Cowper o gland f. Urethra
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Sexual Response Pattern ( 4-phase response by: Masters & Johnson) Process: VASOCONGESTION MYOTONIA
1. EXCITEMENT – 1st phase -- “ foreplay” - women: - vaginal lubrication - vaginal barrel lengthens & distends - cervix & fundus are pulled upward 2
- clitoris increase in size - men: - erection - scrotal skin becomes congested & thick - (both) there is an increase in HR, RR & BP 2. PLATEAU – 2nd stage -- “the entry & coitus phase” - women: - clitoris retracts under the hood - vagina becomes greatly engorged along with labia minora forming “orgasmic platform” - men: - pre-orgasmic emission - testes continues to elevate until they are situated close to the body to facilitate ejaculatory pressure 3. ORGASM – 3rd stage -- “climax” - strong vaginal contractions - occurrence of ejaculation - shortest stage of sexual response cycle 4. RESOLUTION – 4th stage - “phase of relaxation” - the reproductive organs return to their unstimulated state - REFRACTORY PERIOD FEMALE REPRODUCTIVE CYCLE A. Hormones 1. Follicle stimulating hormone (FSH) - initiates the maturation of ovarian follicle - maturation of ovarian follicle 2. Luteinizing hormone (LH) - responsible for ovulation - forms the corpus luteum 3. Estrogen - assists in maturation of ovarian follicle - stimulates the thickening endometrium - FSH suppression - responsible for secondary
sex characteristics - stimulates contraction of smooth muscles 4. Progesterone - increase body temp. - Causes cervical secretions to be thick & viscous - prepares endometrium to receive & nourish fertilized ovum - relaxation of smooth muscles - maintains pregnancy B. Sources 1. Hypothalamus - produces 2 hormones: a. FSH-releasing factor (FSH-RH) b. LH-releasing factor (LH-RH) 2. Pituitary gland - produces FSH & LH 3. Ovaries - Estrogen -Progesterone Menstruation •
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Periodic shedding of blood, mucus & epithelial cells from uterus Ave. blood loss = 30-50 ml
Menstrual Cycle Time between the beginning of one period & beginning of next period Purpose : bring ovum to maturity & renew uterine tissue bed responsible for its growth
Characteristics of Menstrual Cycle: Ave. length – 28 days Ave. flow – 2 - 7 days Normal color – dark red •
Menarche – first menstrual period Menopause – marks end of reproductive life as a result of estrogen depletion Climacteric – transitional period during which ovarian fxn & hormonal prodxn decline (35y/o) OVARIAN CYCLE Follicular Phase (Day 1-14) 1. ovarian follicles mature under the influence of FSH & estrogen 2. LH surge causes ovulation Day 15-28
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Luteal Phase ovum is discharged from mature follicle
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corpus luteum develops under the influence of LH
MENSTRUAL (1-3)
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PROLIFERATIVE (4-14)
OVULATION rupture of graafian follicle & formation of the ovum occurs 14 days before the onset of menstruation 28 day cycle ---20 day cycle ---45 day cycle ---a. MITTELSCHMERZ b. SPINNBARKEIT the ability of the mucus (cervical) to be stretched between 2 fingers about 12-15 cm without breaking ferning pattern (using microscope) c. BASAL BODY TEMPERATURE drops a day before ovulation followed by an abrupt rise after ovulation get temp before rising early AM (at least slept 8 hours prior)
FAMILY PLANNING Calendar/Rhythm Method • -- abstinence during fertile periods -- 1 year menstrual cycle: subtract 18 days from shortest cycle and 11 days from longest cycle * Adv: inexpensive, convenient, no side effects, encourages communication * Disadv: requires long period of abstinence & self-control; Regular mens Coitus Interruptus -- withdrawal of penis from vagina before ejaculation -- least effective method – sperm exist in pre-ejaculatory fluid * Adv: inexpensive, medically safe * Disadv: unreliable, interrupts sexual excitation; Not eliminate risk of STD •
Condom Female :long polyurethane sheath inserted in vagina
with ring at each end; 1 covers cervix & 1 covers labia -- lubricated w/spermicide; inserted up to 8hrs before coitus * Disadv: aesthetically unappealing, expensive for frequent use Male :latex sheath that covers penis & prevents sperm from entering the vagina -- 80% effective
ENDOMETRIAL CYCLE
SECRETORY (15-24)
ISCHEMIC (24-28)
* Adv: prevent conception & transmission of STD -Available OTC; easily carried -Helps maintain erection longer; prevents premature ejaculation * Disadv: decrease spontaneity & sensation Should be used with vaginal jelly if condom/vagina dry; CI in latex allergy • Cervical Cap -- small rubber or plastic dome that fits snugly over the cervix -- provides protection up to 48h Half fill cap with spermicides • Cap should be inserted 30 minutes before • coitus Left in place for 1-2 days • Removal: wash with warm water and mild • unscented soap Replace every 2 years Refitted after pregnancy Diaphragm • -- mechanical device that fits over cervix & prevents sperm from entering cervical os -- used w/spermicide -- left in place 6 hrs after coitus • Intrauterine Device (IUD) -- device inserted into uterine cavity preventing fertilization or implantation -- copper IUD: damages sperm & few reach the ovum -- proges IUD: affects cervical mucus & endometrial maturation -- A/E: increased menstrual flow, uterine infection, ectopic pregnancy, spontaneous expulsion of device • Oral Contraceptive -- combined estro-proges oral preparation -- 97% effective -- prevent conception by inhibiting ovulation Inhibits hypo, pit hormone prodxn -- cause atrophic changes in endometrial lining to prevent implantation -- cause thickening of cervical mucus to inhibit sperm travel CI: smoking, cardiac disease, diabetes, older than 35 yrs old -- S/E: thrombus formation, edema, weight gain, irritability, missed periods, n/v * Adv: most reliable, may alleviate PMS symptoms, dysmenorrhea Protect against ovarian & endometrial cancer * taken Once, same time daily Minipills • -- low dose progesterone given alone --use will result in a thin atrophic endometrium • Subdermal implants 4
-- placement of 6, soft, flexible capsules filled with progesterone Under the skin of the upper arm 8-10 cm above elbow Norplant System ( levonorgestrel ) – * Adv: long-acting ( effective up to 5 yrs ) Subcutaneous Injections • -- Medroxyprogesterone ( DMPA or Depo-Provera ) - injectable progestin: deep IM into gluteal or deltoid q3 mos. -- S/E: spotting, headache, weight gain; Amenorrhea Sterilization: Vasectomy -- surgical ligation of vas deferens terminating sperm passage -- 99.5% effective; performed outpatient basis Nsg. Int: Signed consent • Resume sex after 1 wk with 2 negative sperm • ( after 10-20 ejaculations) Explain does not interfere with sperm prodxn, • can still achieved full erection, ejaculation of seminal fluid with no sperm Mild analgesics & ice pack for pain • •
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Tubal Ligation
-- fallopian tubes surgically ligated or cauterized through laparoscopy or minilaparotomy --prevents impregnation of ovum by sperm - done after menstruation or before ovulation - provides immediate contraception Nsg. Int: • resume sex after 2-3 days does not affect menstrual cycle may be performed postpartum
- nausea & vomiting - headache 2. PMS (Pre- Menstrual Syndrome) - cause: unknown, but may be due to the drop in progesterone just before menses S/S: a. b. c. d. e. f. Nursing Care: a. restrict foods with methylxanthines, fat, salt sugar b. complex CHO’s, CHON c. increase frequency of meals d. Vit. B & Vit. E supplement e. Regular exercise f. Meds - pain – - edema – - breast tenderness – 3. AMENORRHEA a. Primary - woman has never menstruated - caused by congenital defects, problems with the uterus b. Secondary - cessation of menstruation - may be caused by pregnancy, take of oral pills, menopause or even stress Mgt: ovulatory drug: CLOMID (clomiphene citrate)
MENSTRUAL DISORDERS 1. DYSMENORRHEA Types: a. Primary – Mgt: b. Secondary -- Pain with an underlying pathology uterine myomas, PID, endometriosis Mgt:
4. MENORRHAGIA - excessive or prolonged menstrual flow 5. METRRORHAGIA - bleeding between menses may indicate uterine carcinoma or ovarian cyst •
Bleeding o
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Mild: no interference with normal activity Moderate: some interference Severe: interference w/majority of ADL’s
> Manifestation: - “bloated feeling” - light cramping 24h before mens - colicky pain - mild diarrhea - mild breast tenderness
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Perineal pad count Monitor V/S
HEARINFERTILITY inability to conceive after at least 1 year without contraception
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Primary infertility – no previous history of either partner conceiving or impregnating Secondary infertility – inability to conceive after a previous successful pregnancy
Therapeutic Management: 1. Education about menstrual cycle & sexual therapy 2. Medications: Clomiphene citrate (Clomid) • -- ovulatory stimulant -- follicle-maturing agent used during the fifth to tenth day of the menstrual cycle -- S/E: multiple pregnancy (Pergonal) human menopausal gonadotropin • -- acts similarly to FSH or LH to stimulate growth & maturation of ovarian follicle Bromocriptine (Parlodel) • -- inhibits release of prolactin= anovulatory hormone Medical Intervention
Artificial Insemination -- technique is used to instill the sperm into the cervix or uterus to aid in conception
capacitation – physiologic removal of the acrosome acrosome reaction HYALURONIDASE – zona pellucida – protective covering of the ovum corona radiata – cells that encircles the zona pellucida II. Conception / Fertilization a. zona reaction ovum becomes impenetrable to other sperm b. fertilization the beginning of pregnancy the union of ovum and sperm life span of ovum – 24-48 hours life span of sperm – 24-72 hours Sex determination: >ovum – 23 chromosomes : >sperm – 23 chromosome : zygote – fertilized ovum to implantation single cell, the product of fertilization
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In vitro fertilization -- used when damaged or obstructed fallopian tubes impair transport of a fertilized egg to the uterus •
Gamete intrafallopian transfer ( GIFT ) -- an ovum is surgically retrieved from the ovary & implanted into the fallopian tube -- sperm implanted into the fallopian tube •
Zygote intrafallopian transfer ( ZIFT ) -- ovum fertilized externally -- fertilized zygote is then returned to the fallopian tube by a laparoscope •
III. Implantation a. Blastomere b. Morula c. Blastocyst 1. Trophoblast – outer portion 2. Embryoblast – inner portion d. Implants -- 7 to 10 days after fertilization A. EMBRYONIC MEMBRANES 1. Chorion -- outer membrane 2. Amnion -- inner membrane Deciduas a. decidua basalis forms the maternal side of the placenta underlies the embryo b. decidua capsularis overlies the embryo c. decidua parietalis/vera lies the rest of the uterine cavity does not come in contact with the fetus GERM LAYERS Ectoderm – amniotic cavity • Entoderm – yolk sac -- supplies nourishment • only until implantation; * provide source of RBC Mesoderm • 8 wks gestation= all organ system complete •
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Surrogate mothering -- used when a woman not able to conceive & unable to carry a fetus to viability -- semen from the infertile woman’s partner is artificially inseminated nto the host (surrogate mother) FERTILIZATION / IMPLANTATION
I. Prefertilization Ovum moves to the ampulla by means of peristaltic movement - sperms move into the ampulla by means of their tail
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Ectoderm -
CNS PNS Sense organs Skin, hair, nails
Mesoderm
Entoderm
-Heart -Reproductive System -Circulatory System - Upper portion of URI (kidney, ureter)
-lower URI system -lining of GI tract, Respi tract, pericardial, pleura, peritoneal cavities
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B. AMNIOTIC FLUID slightly yellow and transparent derived from fetal urine and fluid from mother ave. amt: 800-1200 ml ph: 7.2 slightly alkaline -
3. Estrogen -- “HORMONE OF WOMEN” 4. Progesterone -- “HORMONE OF MOTHERS”
OLIGOHYDRAMNIOS = amniotic fluid less than 300ml or no packet on ultrasound larger than 1cm POLYHYDRAMNIOS/HYDRAMNIOS = more than 2000ml amniotic fluid or pockets of fluid larger than 8cm on ultrasound Functions: 1. Cushion the fetus 2. Maintain even temperature 3. Provide source of oral intake for the fetus 4. Protects umbilical cord from pressure 5. Allows the fetus to move freely
2 Components of the Placenta: 1. Maternal -- rough/dirty where it attaches to uterus 2. Fetal side -- smooth & shiny D. UMBILICAL CORD “funis” links the placenta to the baby & to the mother a. 2 arteries carries deoxygenated blood & waste products from the fetus to the placenta b. 1 vein carries freshly oxygenated and nutrient- laden blood from the placenta back to the fetus c. wharton’s jelly - connective tissue that sorrounds the blood vessels & protects the vessels from compression
C. PLACENTA
“pancake” develops at the 3 rd week of gestation; functional: 2 Functions: 1. Metabolic function produces nutrients needed by the embryo synthesis of glycogen, cholesterol & fatty acids -
1. 2. Endocrine function secretes 4 hormones: 1. Human Chorionic Gonadotropin (HCG) sustains the life of corpus luteum causes the corpus luteum to persist to continue secretion of estrogen & progesterone
2. Human Placental Lactogen (HPL) also called Human Chorionic Somatomammotropin promotes normal nutrition & growth of the fetus
promotes maternal breast dev’t for lactation
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FETAL DEVELOPMENT Circulatory System 3rd week – heart beats 4th–5th week – heart’s chamber develop Respiratory System 11th week – respiratory movement 24th week – surfactant production Renal System 5th week – kidney function 12th week – urine formation full term - fully develop kidney Neuromuscular System 11th-12th week – fetal movement 20th week – distinguishes taste 24th week – responds to sounds 28th week – opens eyes
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full term – brain is ¼ the size of an adult’s
brain 5. Gastrointestinal System 9th week – synthesizes glycogen 16th week – formation of meconium 6. Endocrine System 3rd-4th week – formation of thyroid gland 8th week – secretes thyroxin 12th week – pancreas produces insulin 7. Reproductive System 8th week – genital appears 12th week – sex differentiation 8. Musculoskeletal System 6th week – development of bones 7th week – contraction of muscles 9. Integumentary System 12th week – lanugo appears 16th week – hand & footprints appear 20th week – vernix caseosa appears 28th week – lanugo thins 32nd week – subcutaneous fats thickens 10. Immune System 24th week – IgG cross placenta passive immunity until 2 mos. PREGNANCY Gravida Para Duration of Pregnancy CONFIRMATION OF PREGNANCY A. Presumptive Signs subjective signs least indicative of pregnancy largely felt by the mother 1. amenorrhea impregnation has occurred stress anemia strenuous exercise 2. nausea & vomiting increase HCG level GI disorder Emotional stress 3. frequent urination pressure of the uterus to the bladder UTI 4. fatigue fetus is using the mother’s glucose rapidly illness overexertion 5. quickening fetal movement felt by the mother Primigravida: 20 weeks Multigravida: 16 weeks presence of gas in intestine may also stimulate same sensation
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pigmentations – 24th week chloasma (mask of pregnancy) Striae gravidarum ( stretch marks) Linea nigra breast changes - usually noticeable during 1st pregnancy
B. Probable Signs
objective signs signs that can be documented by the examiner still they are not foolproof 1. abdominal enlargement 2. ballottement - sinking and rebounding of the fetus in it’s surrounding amniotic fluid 3. Hegar’s sign softening of the lower uterine segment 4. Chadwick’s sign bluish discoloration of the vagina rapidly growing uterine tumor at 6th week but easily noted at 8 th week 5. Goodell’s sign softening of the cervix 6. Braxton Hicks’s contraction painless, palpable contractions 7. positive pregnancy test measures the HCG secreted by the chorionic villi of implanted ovum 8. Ladin’s sign presence of a soft spot in the middle of the uterus 9. Braun Von Fernwald’s sign irregular enlargement @ the site of implantation 10. Piskacek’s sign tumor like enlargement of the uterus -
C. Positive Signs 1. Auscultation of fetal heart sounds 18th-20th weeks gestation by fetoscope 10th-12th weeks by Doppler 2. Fetal movements felt by the examiner 3. Visualization of embryo or fetus ultrasound confirms pregnancy as early as 5-6 weeks gestation by the presence of gestational sac PHYSIOLOGIC CHANGES OF PREGNANCY 1. Breasts -
increase in size & nodularity enlarged Montgomery’s tubercles 8
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veins become prominent precolostrums can be expressed from nipples as early as 12 th-14th weeks
2. Uterus
- increase in vascularity - presence Hegar’s sign 3. Cervix -
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formation of mucus plug or operculum presence of Goodell’s sign
4. Vagina
- Chadwick’s sign Leukorrhea – 5. Cardiovascular System increase in blood volume increase in cardiac output varicosities supine hypotension 6. Respiratory System increase O2 demand increase chest circumference displacement of the diaphragm 7. Gastrointestinal System swollen gums (“epulis of pregnancy”) constipation heartburn hemorrhoids 8. Urinary System urinary stasis urinary frequency 9. Musculoskeletal System lordosis (pride of pregnancy) characteristics waddle diastasis recti 10. Integumentary System chloasma/melasma linea negra striae gravidarum 11. Endocrine System increase activity & hormone production slight hyperparathyroidism enlargement of the thyroid gland increase melanocyte stimulating hormone PSYCHOLOGIC CHANGES OF PREGNANCY
2. Second Trimester alternate feelings of emotional well being & liability acceptance of pregnancy possible increase in sex drive adjustment to change in body image TASK: Accepting the baby, “A baby is growing inside me” 3. Third Trimester feelings of awkwardness & clumsiness renewed fears & tension about labor spurt of energy during the last month “Nesting Instincts” TASK: Preparing for parenthood, “I am a mother” COUVADE SYNDROME group of physiological & behavioral manifestation experienced by the husband are often the result of stress, anxiety & empathy for the pregnant women ANTEPARTUM ASSESSMENT & CARE 1. Frequency of visit 1-7 months: every month 8 months: every 2 weeks 9 months: every week
2. Estimates a. EDD / EDC Naegel’s Rule 1st day of LMP subtract 3 months add 7 days change the year •
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Fetal length Haase’s Rule 1 to 5 months (multiply the age of pregnancy by itself) Ex: 4 months x 4 = 16 cm •
-PREGNANCY: Maturational Crisis 1. First Trimester ambivalence fear fantasies about motherhood & about having a “dreamchild” possible decrease in sex drive TASK: Accepting the pregnancy, “I am pregnant”
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6 to 9 months (multiply by 5) Mc Donald’s Rule - lunar months fundal height(cm) x 2/7 Ex: 14 cm x 2/7 = 4 months - Weeks: fundal height (cm)x8/7=16
weeks 9
Ex: 14 cm x 8/7 = 16 weeks 3. Assessment a. Demographic Data -address, telephone number, race/ethnic group, religion, health insurance b. Family profile - identify support system, size of house, her age & partner’s age, educational levels, occupation c. Family history - Inherited disease - Congenital Anomalies d. Past medical history - Cardiac, kidney, STD’s, DM, Thyroid, Respiratory, Surgical procedures, Injuries, Childhood Diseases, Allergies/ drug sensitivities e. Social profile Information of woman’s lifestyle: • Exercise – Hobbies – Smoking – Drinking habits – Medication history; Recreational – drugs f. Gynecologic history a. Reproductive tract b. Breast problem c. Menarche d. Menstrual cycle (interval, duration, amount, discomfort) e. Past surgery on reproductive tract f. Reproductive planning method g. Sexual history g. Obstetric history G - # of pregnancies T – term pregnancy P – preterm pregnancy A – abortion L – living children M – multiple pregnancies Physical Examination vital signs height & weight pelvic measurement -
abdomen Fundal Heights: Fundus @ the symphysis pubis – 12 weeks Fundus @ the umbilicus – 20 weeks Fundus @ 28 cm from top of symphysis pubis – 28 weeks Fundus @ lower border of rib cage (xiphoid process)– 36 weeks -
Hgb < 11 g/dl or Hct < 32% requires iron supplementation 3. CBC = to detect infection or cell abnormalities - increase or 15,000 more or decrease requires follow up 4. Rh factor = for possible maternal-fetal blood incompatibility 5. VDRL = serologic test for syphilis 6. Urinalysis = test for albuminuria, glucosuria, pyuria -
Leopold’s Maneuver a systematic way of observation & palpation to determine fetal position Preparation: 1. 2.
Steps: 1. Palpate what is lying in the fundus. BREECH – round, that, hard, mobile CEPHALIC – irregular, soft, non-mobile
2. Palpate fetal back in relation to the right & the left. 3. Locate presenting part @ pelvic inlet & check for engagement. 4. Palpate just above the inguinal the relationship of the presenting part to the pelvis. Assessing the Fetal Heart Ton es Fetal Heart Tones a very rapid, somewhat muffled ticking sound Normal: 120-160bpm Uterine Bruit/ Souffle a soft murmur caused by the passage of blood thru the uterine vessels synchronous with maternal pulse 2. Funic Souffle hissing sound produced by passage of blood thru the umbilical arteries synchronous with FHB VARIATIONS IN FETAL HEART BEAT 1.
Early deceleration
caused by fetal head compression Mgt:: no intervention required Late Deceleration caused by uteroplacental insufficiency -
2. Laboratory tests: 1. Blood grouping = to determine the blood type 2. Hgb/Hct = to detect anemia
Pos’n:
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Mgt: change the woman’s position to left side 3. Variable deceleration - caused by umbilical cord compression Mgt: change the woman’s position to relieve pressure on the cord
Interpretation: REACTIVE: NON-REACTIVE: III – OXYTOCIN CHALLENGE TEST (OCT) / CONTRACTIONS STRESS TEST (CST) done for evaluation of the ability of the fetus to withstand the stress of uterine contractions
ASSESSMENT OF FETAL MATURITY & WELL BEING done during the 26th week of gestation
Indication: If the woman has a non reactive non stress test
I – AMNIOCENTESIS removal of amniotic fluid from the uterine cavity st early 1 trimester – rd 3 trimester –
Procedure: Diluted IV Oxytocin is given via infusion pump
Preparations: - Let the patient void - Supine position attached to the sonogram - Rolled towels a. Lecithin/Spingomyelin (L/S) Ratio measures maturity of fetal lung the protein component of the enzyme surfactant Normal Ratio 2:1 -
Interpretation: Negative: * No Late Deceleration Positive: * Indicates Placental Insufficency
HEALTH EDUCATION 1.
Weight gain
Normal weight 2-5 lbs – 1st trimester 1 lb/week – 2nd & 3rd trimester Total Weight Gain: 25-35 lbs Underweight: 28-40 lbs Overweight: 35-45 lbs
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b. Alpha-Feto Protein major plasma of early fetus decrease after 13 weeks of gestation with AFP: neural tube defect -
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Nutrition
Calories – increase 300 K POST AMNIOCENTESIS: a.
II – NON STRESS TEST (NST) used to evaluate FHR in response to fetal activity
cal/day CHON – 4 servings of meat recommended or 60 g/day Ca – 1200 mg/day Folate – 400 ug/day Iron – 30 mg/day 3.
Rest -
Indications: a. b. c. Procedure: woman is placed in semi fowlers position external fetal monitor is attached to the abdomen fetal heart beat & fetal movement are recorded on the same strip of paper •
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encourage mother to sit down & elevate the feet 10 hours of sleep
Exercise -
amount & type of exercise depend on the physical condition of the woman & stage of pregnancy a. Walking – most ideal exercise b. Kegels exercise – aid in restoration of perineal muscles & prevent stress incontinence 11
c. Tailor sitting – for relief of backache d. Pelvic tilt – for relief of backache e. Shoulder circling – for relief of backache 5.
Sexual Relations -- no restrictions -- CI: vaginal bleeding, ruptured membranes - strong uterine contraction after orgasm Common Discomforts of Pregnancy a. nausea & vomiting eat crackers before arising Mgt: in morning eat small frequent meals avoid fried, greasy, spicy foods b. heartburn Mgt: eat small, several meals avoid smoking & coffee (cause hyperacidity) sit upright especially after meals c. constipation Mgt: drink @ least 8 glasses of H20 a day increase fiber in diet exercise d. Varicosities Mgt: avoid constricting clothing avoid crossing legs at the knees take frequent rest periods with legs elevated wear support hose or elastic stockings e. hemorrhoids hot sitz bath Mgt: -- apply cool witch hazel compound -- knee chest f. leg cramps Mgt: dorsiflexion g. frequent urination Mgt: will be resolved without intervention. However, you can use Kegel’s exercise to lessen the discomfort h. backache Mgt: - tailor sitting - shoulder circling - pelvic rock - squat rather than bend when lifting −
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Leukorrhea Mgt: wear perineal pads clean perineal area always (front to back) j. Hypotension Mgt: L side lying position k. Dyspnea Mgt: elevate head of bed l. Ankle edema - reduced blood circulation in lower extremities Mgt: - avoid constricting clothing Pica - compulsion to ingest non-food substances - assoc. with Iron Deficiency Anemia Mgt: - iron supplements
DANGER SIGNS OF PREGNANCY
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a. vaginal spotting/bleeding b. leaking of fluid from the vagina c. unusual abdominal cramps -- ectopic pregnancy in 1 st trimester & abruptio placenta in 3 rd trimester d. persistent headache, blurring of vision a. marked swelling of hands & feet b. painful, burning urination discharge c. foul smelling vaginal discharge d. chills & fever e. persistent nausea & vomiting
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LABOR & DELIVERY A. Theories 1. Uterine Stretch - as the uterus becomes stretched, pressure increases & physiologic changes occurs = initiation of labor 2. Oxytocin - as pregnancy progresses, uterus becomes more sensitive to oxytocin 3. Progesterone deprivation - decrease level of progesterone results to smooth muscle contraction 4. Prostaglandin cascade - there is an increase level of prostaglandin during the late month of pregnancy - results to uterine contraction B. Mechanics 1. Passage 12
a. Gynecoid -- normal female pelvis - ideal for childbirth - round shape pelvic inlet b. Android -- male pelvis - heart shaped
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13.5 cm
Fetal lie - comparison of the long axis of the fetus to the long axis of the mother --transverse --longitudinal
pelvic inlet c. Anthropoid -- “ape like”
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pelvis - oval shaped pelvic inlet d.Platypelloid -- flattened pelvis - reverse oval shaped 2. •
Passenger Fetal bones
- 2 frontal bones - 2 parietal bones - occipital bone (bones that are involved in birth process) •
Suture lines
- strong but flexible tissue that connects 5 major bones --coronal suture --saguittal suture --lambdoidal suture --frontal suture •
Fontanels
- spaces @ the intersection connecting the skull anterior fontanel – diamond shape posterior fontanel – inverted triangle •
Head measurements 1. Biparietal diameter - measurement from 1 parietal prominence to another - 9.25 cm 2. Suboccipitobregmatic diameter - measures from the undersurface of the occiput to the center of the anterior fontanel - 9.5 cm 3. Occipitofrontal diameter - measures from posterior fontanel to the bridge of the nose - 11/11.75 cm 4. Occipitomental diameter - measures from the occipital bone to the chin/mentum
Fetal attitude - relationship of fetal parts to each other --good flexion --moderate flexion --poor flexion
Fetal presentation b. relationship of presenting part to the mother’s cervix Cephalic - most favorable presentation Reasons: a. fetal head is the largest single fetal part, after it is born, the smaller parts follow easily b. fetal head can gradually change shape, molding to adapt to the size & shape of the maternal pelvis c. fetal head is smooth, round & hard, making it more effective part to dilate the cervix Types of Cephalic Presentation a. Vertex - most common - fetal head fully flexed - suboccipitobregmatic diameter is presenting b. Military - fetal head is in neutral position - neither flexed nor extended c. occipitofrontal diameter is presenting c. Brow - fetal head is partly extended - unstable d. Face - poor flexion - complete extension of all body parts •
•
Breech (Buttocks)
Disadvantages:
13
- less effective in dilating cervix - fetal head is the last part to come out 3 Variations: a. Frank Breech --most common --hips are flexed but the knees are extended to rest on the chest --the buttocks alone present to the cervix b. Complete breech --the fetus has thighs tightly flexed on the abdomen --both the buttocks & the tightly flexed feet present to the cervix c. Footling --one foot presents: Single Footling --if both present: Double Footling
1. 2. 3.
Increment Acme/Peak Decrement
B. Assessment 1. Frequency -- from the beginning of 1 uterine contraction to the beginning of the next -- expressed in minutes (3-4 mins) 2. Duration -- length of each contraction from the beginning to end -- express in seconds : 30 secs 3. Interval/ Relaxation -- period between the end of 1 contraction & the beginning of the next 4. Intensity -- strength of contractions -- express in mild, moderate, strong 4. PSYCHE -- mental preparation of the mother for labor & delivery -- marked anxiety or fear -- relaxation PREPARATION FOR CHILDBIRTH
Shoulder/Transverse Presentation -the shoulders is in transverse lie •
Fetal station = the relationship of the presenting part to the level of the ischial parts -4 -3 floating: 3cm above -2 floating: 2cm above -1 floating: 1 cm above 0 ischial spine: +1: 1cm below the ischial spine +2 2cm below the ischial spine +3 3cm below the ischial spine +4
Fetal Position = relationship of fetal presenting parts to the mother’s pelvic quadrants Nomenclature Position/Presentation/Variety – 3 Letters – 1st letter: landmark pointing to mother’s [ R or L ] 2nd letter: fetal landmark [ O, M, Sa, A ] 3rd letter: landmark points [ A, P, T ]. •
•
3.
POWER
A. Phases
1. Dick - Read - slow abdominal breathing in early labor & rapid chest breathing in advance labor 2. Bradley - include the father as a support person for “husband-coached childbirth” 3. Le Boyer - views birth as a traumatic experience fro the neonate - lights are dimmed & noise is decreased during delivery to keep the newborn adapt to extrauterine life more easily 4. Lamaze - called “psychoprophylaxis”, because it uses the mind to prevent pain - uses relaxation & breathing exercises, imagery or massage as pain relief measures - support person: a husband or a coach 5. Kitzinger - program of conscious relaxation & levels of progressive breathing - uses sensory memory - Sheila Kitzinger SIGNS OF IMPENDING LABOR 1. Lightening - settling of the fetus in the lower uterine segment - effects: 2. Braxton-Hicks contraction - becomes more noticeable & painful in the last month of pregnancy 14
- strong frequent but irregular uterine contractions 3. GI upset - women frequently experience diarrhea, indigestion or nausea & vomiting few days before labor 4. Burst of energy - “nesting”, the pregnant woman is busy preparing the things of her baby 5. Blood Show - mucus plug is discharged from the cervix along with a small amount of blood 6. Ruptured BOW TRUE LABOR VS. FALSE LABOR 1. Contractions TRUE: regular, become more frequent, gradual increase in duration & intensity FALSE: irregular, not intense 2. Discomforts TRUE: begins @ the lower back & radiates around abdomen FALSE: primarily on the abdomen only 3. Effects of Walking TRUE: contractions are intensified when walking FALSE: contractions may decrease or disappear when walking 4. Cervical changes TRUE: progressive dilatation & effacement FALSE: no cervical changes
diagonal or transverse position to deliver the shoulders F. Expulsion - once the shoulders are delivered, the rest of the baby is delivered easily & smoothly because of its smaller size STAGES OF LABOR A. First Stage (Stage of Dilatation) 3 Phases: 1. Latent Phase > > > Mgt: 1. 2.
3. 4. 5.
encourage ambulation check V/S, FHR, contraction clear fluids or ice chips left-side lying position breathing techniques:
6. 2. Active > > Mgt: 1. 2. 3.
encourage voiding Q2H
Phase
check V/S, FHR, contractions calm environment comfort measures
CARDINAL MOVEMENTS (Mechanisms of Labor) A. Descent - downward movement of the biparietal diameter of the fetal head to within the pelvic inlet B. Flexion - baby moves further downward & then head meets obstruction at the pelvic floor causing flexion C. Internal Rotation - for the head to pass the pelvic outlet - the head flexes as it touches the pelvic floor, & the occiput rotates until it is suspended, or just below the symphysis pubis, bringing the head into the outlet of the pelvis D. Extension - occurs as the fetal head passes beneath the symphysis pubis - after internal rotation, head of the baby extends with position still the same so that the face & neck can come out E. External Rotation - almost immediately after the infant’s head is born, the head rotates back into the
4. breathing techniques:
5. IVF 6. provide psychosocial support 7. Analgesia – Meperidine HCl (Demerol) – IV or IM -- admin during Active labor [ 4-7 cm ] -- to allow metabolism & excretion of drug before birth to avoid respi depression in newborn 3. Transition Phase > > > Mgt: 1. check V/S, FHR, contractions 2. be alert for bladder distention 3. I.E. 4. avoid pushing 5. provide short, concise information 6. breathing technique:
15
7. nausea & vomiting may occur B.
bladder impedes the descent of the baby 7. episiotomy Types: Median/Midline Mediolateral Purposes: a.to avoid laceration of the perineum b. to shorten the 2nd stage of labor c. to avoid prolonged pressure on infant’s head
Second Stage (Stage of Expulsion) Mgt: 1. check V/S, FHR, contractions 2. I.E. 3. positioning lithotomy position with head elevated 4. perineal prep 5. breathing technique: 2 short breaths, hold 3 rd breath while pushing 8. Hand Maneuver never open mouth a. Ritgen’s 6. catheterization maneuver may be done to avoid bladder distention because a full pressing forward on the chin of the fetal head while pressing the other hand downward on the fetal occiput b. palpate for cord coil c. suction baby’s mouth & nose using a bulb syringe d. deliver the shoulder, wait for the external rotation where 1 shoulder is up & the other shoulder is down e. one hand @ the back of the neck, the other one grasping the extremities & put the baby in the mother’s abdomen & suction 9. Cord clamping & cutting milk the cord towards the Nsg. Considerations: baby 1. Monitor client. Assess BP cut the cord when it stops before admin pulsating 2. O2 & emergency resuscitative equipment at bedside 3. Use infusion pump, piggyback C. Third Stage (Placental Stage) 4. Stop infusion if prolonged 1. Placental Separation a. Calkin’s sign uterine contractions b. gushing of blood 5. -- lasting more than 2mins, c. lengthening of the 70secs duration cord 2. Placental Expulsion 2. Inspect the placenta -- Brandt – Andrews 3. Episiorraphy Maneuver a. Shultz Mechanism Perineal Lacerations: a. Duncan Mechanism First Degree • Mgt: -- mucous membrane & skin only 1. Medication Second Degree • a. Oxytocin -- tear into muscles of perineal body but (Syntocinon) exclude rectal sphincter - given IV Third Degree • after delivery -- involve circular anal sphincter muscle of baby Fourth Degree • b. Methylergonovin -- involves rectovaginal wall e Maleate Initial Newborn Care (Methergine) - given IM after 1. Establish & maintain patent airway delivery of the -- suction with bulb syringe mouth then nose placenta Major S/E: Maternal 2. Evaluation of APGAR score Hypertension -- [ 1st min & 5 min ] • Dysrhythmias Purpose: assess adaptability to extrauterine • Hypertonic uterus life • Water intoxication Mgt: 7-1o – good • 16
3-6 – moderately depressed ( admin O2 )
- “afterpains” – abdominal pain associated with uterine contractions
0-2 – severely depressed ( resuscitation ) PUERPERIUM -- delivery – 6 to 7 weeks
3. Maintain body temperature -- drying infant, radiant warmer Evaporation – Radiation – Convection – Conduction –
1. Postpartal Bleeding -- bleeding in excess of 500ml within 24hrs following birth -- assoc with uterine atony, lacerations, retained placental fragments
4. Promote parent bonding - en face position – 5. Assess for gross physical abnormalities Assess gestational age: - AGA= weight between 10th & 19th percentile - LGA = wt. above 19th percentile - SGA = wt. below 10th percentile for age - LBW = wt. 2500g or less 6.
Identification of infant [ footprints ]
7.
Eye care: prophylactic eye treatment -- opthalmia neonatorum
- silver nitrate 1% - erythromycin or tetracycline 8. Vitamin K administration -- 0.5 to 1mg single IM vastus lateralis --to prevent hemorrhagic dse.
Mgt: – – – –
Monitor vital signs Uterine massage Insert Foley cath; MIO Admin oxytocin Monitor bleeding; perineal pad count
2. Breast care -wash only with water -air drying -wear bra Breastfeeding: a. warm shower b. express milk manually Bottlefeeding: a. avoid handling the breasts b. ice bag to breasts c. analgesic for pain Breast Engorgement -- occur at 3rd day --attributed to milk “coming
in” D.
--resolves within 48h --hard, nodular breast
Fourth Stage (Stage of Physical Recovery)
Mgt: 1. Assess uterine contractility - uterus must be firm & well contracted - check for uterine involution 1 H after delivery: uterus @ the level of the umbilicus 1 day after delivery: uterus 1 fingerbreadth below umbilicus (1cm) nd th 2 -9 day – 1 fingerbreadth a day th 10 day – nonpalpable.
Mastitis -- Inflammation of breast tissue usually caused by infection or stasis of milk in the ducts -- occurs at 7th postpartal
day -- CA: – – – – –
2. Assess for lochial discharge a. Lochia rubra b. Lochia serosa c. Lochia alba 3. Assess perineum for bleeding
Mgt: Frequent emptying of breast (q 2hrs) Apply warm compress Encourage to wear supportive bra Administer antibiotics as prescribed Comfort measures: small side pillow
3. Resumption of sex intercourse may be resumed when perineal & uterine wounds have healed (2-4 weeks)
4. Assess for level of pains 17
4. Return of Menstruation for breastfeeding mother: within 4 months bottlefeeds: within 4-8 weeks -
loss of a fetus before the age of viability ( 20 weeks or 500 gms) often associated with embryonic or trophoblastic disease
-
PSYCHOSOCIAL ADAPTATION 1. Taking – in Phase st happens 1 3 days passive dependence time for reflection little interest in taking care of her child 2. Taking–hold Phase independence woman already shows interest in taking care of her baby 3. Letting-go Phase redefining new role POSTPARTUM BLUES Onset: Symptoms: sadness, fears Incidence: 75% of all births Etiology: probable hormonal changes, life changes Therapy: support, empathy Nursing Role: offer compassion & understanding POSTPARTAL DEPRESSION Onset: Symptoms: anxiety, feeling of loss, sadness Incidence: 10% of all births Etiology: history of poor parent relationship, hormonal response Therapy: counseling Nursing Role: refer for counseling POSTPARTAL PSYCHOSIS Onset: Symptoms: delusions, hallucinations Incidence: 2% of all births Etiology: activation of previous mental illness, hormonal changes Therapy: psychotherapy, drug therapy Nursing role: refer for counseling, safeguard mother from injury to self or newborn *COMPLICATIONS OF PREGNANCY* BLEEDING DISORDERS OF THE 1ST TRIMESTER A. Spontaneous Abortion
Classification: 1. Threatened Abortion = vaginal bleeding or spotting (with no or slight abdominal cramps) = cervix is closed Mgt: a. b. avoid 2. Inevitable/Imminent Abortion Mgt: a. save tissue fragments for examination b. if no FHB – IV oxytocin is used to expel the product of conception c. D & E 3. Complete Abortion - entire contents of conception are expelled (fetus, placenta) - minimal bleeding Mgt: a. no further treatment is required b. monitoring (check for infection) 4. Incomplete Abortion - usually fetus is expelled but the membranes & placenta were retained - massive bleeding Mgt: a. Dilatation & Curettage (D&C) 5. Missed Abortion fetus dies in utero but is not expelled Mgt: a. Evacuation b. Dilatation & Curettage 6. Habitual or Recurrent 3 spontaneous abortions occurring successively Mgt: a.depends on what type of abortion B. Induced Abortion
voluntary method of terminating pregnancy Purposes: a. preserve health of the mother b. prevent the birth of an infant with severe gastric defects c. end pregnancy caused by rape or incest d. to terminate the pregnancy of woman who chooses not to have a child @ this time in her life – MAJORITY OF REASONS -
18
Types: 1. Therapeutic = termination of pregnancy done for the purpose of safeguarding the health of the mother 2. Elective = interruption of pregnancy at the request of the woman but not for reasons of impaired maternal health or fetal distress Methods: a. Vacuum aspiration or curettage - done up to 13 weeks of gestation - cervix is dilated by metal rods then the Curette -- to ensure that it is empty - cramping is expected 20-30 mins after b. Dilatation & Evacuation - done from 13 weeks to 16 weeks of gestation - cervix is dilated with: - Laminaria - Prostaglandin Gel c. Labor Induction - done on 16th week up to 24thweek gestation C. Ectopic Pregnancy -
defined as extrauterine pregnancy
Sites: 1. cervix 2. fallopian tube – most common 3. ovaries 4. abdomen Causes: 1. narrowing of the tube 2. pelvic infection 3. endometriosis 4. smoking Manifestations: 1. vaginal bleeding 2. knife-like abdominal pain 3. referred pain on the shoulder 4. symptoms of shock 5. pelvic pressure or fullness 6. pelvic mass 7. Cullen’s sign Diagnosis: 1. Culdocentesis 2. UTZ 3. Hysterosalphingogram Mgt: 1. monitor amount of bleeding
•
•
2. monitor V/S 3. assess/observe for abdominal pain 4. blood transfusion 5. prepare for surgery Salpingostomy Salpingectomy Oophorectomy 6. psychological/emotional care DOC: Methotrexate + Leucoverin -- attacks & destroys fast-growing cells -- folic acid antagonist Mifepristone -- abortifacient -- cause sloughing off of tubal implantation
BLEEDING DISORDERS OF THE 2ND TRIMESTER
1. Hydatidiform Mole (H mole) also called Gestational Trophoblastic Neoplasm characterized by proliferation of chorionic villi into mass of clear vesicles Predisposing Factors: a. low socio economic status b. women below 18 or above 35 y.o. c. intake of Clomid d. women of Asian heritage Types: 1. Complete/Classic 2. Incomplete/Partial Manifestations: a. vaginal bleeding b. excessive nausea & vomiting c. rapid enlargement of uterus d. (+) pregnancy test e. abdominal cramps f. absent FHR g. elevated HCG titer: 1-2m IU Mgt: a. D&C b. Chemotherapy c. Monitor HCG level d. Delay childbearing for 1 year e. Perineal pad count f. Chest X-ray
2. Incompetent Cervix painless, premature dilation of the cervix without labor Causes: a. congenital anomaly b. trauma Risks: a. Habitual abortion b. Preterm labor Manifestations: 19
a. vaginal bleeding/show b. painless dilatation c. premature rupture of membranes Mgt: a. b.
Predisposing Factors: 1. chronic hypertensive disease 2. multigravida 3. history of short cord 4. trauma 5. inhalation of cocaine Types: 1. Covert or Central 2. Partial/Marginal 3. Complete/Total
bed rest in T-position medications: Tocolytics
c. surgery *Cervical Cerclage a. Shirodkar-Bartor b. Mc Donald’s
Complications:
1. Couvelaire Uterus 2. shock 3. DIC (Disseminated Intravascular Coagulation)
BLEEDING DISORDERS IN THE 3RD TRIMESTER A. Placenta Previa Predisposing Factors: 1. multiparity 2. advanced maternal age 3. alteration in uterine structure Types: 1. Low-lying or Marginal 2. Partial/Incomplete 3. Total/Complete
^^Interventions:
1. bedrest in side lying position 2. Tocolysis 3. no IE/enema 4. IVF 5. adm O2 as ordered 6. perineal pad count 7. assess s/s of shock 8. monitor fetal status 9. psychological support
B. Abruptio Placenta
PREVIA
ABRUPTIO
Abnormal implantation Multiparity
Premature separation HTN, cocaine use, trauma
• • •
• • •
Painless bleeding Bright red Without contractions
Painful bleeding Dark red or brown Rigid, boardlike uterus
Int! • • • •
Monitor VS Assess bleeding No IE/enema Bed rest
C. PREMATURE RUPTURE OF MEMBRANES (PROM) Contributing Factors: a. infection of the vagina b. incompetent cervix c. hydramnios d. amniotic sac with weak structure e. recent sexual intercourse Complications: a. Infection
Int! • • • •
Monitor VS Assess bleeding Oxygen 6-10L/min IV/Foley cath
b. c. Dx: a. Mgt: a.
b.
RDS Cord Prolapse Nitrazine Test Gestation Near Term - induction - CS may be done Preterm gestation - complications of prematurity - cervix is usually not favorable for induction - CS may be done 20
Nsg. Intervention: a. check FHR b. check vaginally for prolapsed umbilical cord, or in case of advance labor for descent of presenting part c. check the color of amniotic fluid Normal: clear Meconium Stained: Cephalic – Breech –
PREMATURE LABOR & BIRTH Contributing Factors: a. multiple gestation b. polyhydramnios c. premature rupture of membranes d. incompetent cervix e. placenta previa/abruptio placenta f. previous preterm labor Mgt: a. Prevention of Premature Delivery - if woman is currently in preterm labor, she is admitted to the hospital - induction may be done if labor does not begin spontaneously - CS may be done b. Patient Teaching - teach woman symptoms of preterm labor uterine contractions in regular pattern for more than 1 hour while @ rest intermittent or constant uterine cramps low, dull backache intestinal cramping rupture of membrane MULTIPLE GESTATION Types: a. Monozygotic Twins “ identical twins” --only same sex --1 ovum, 1 sperm --1 placenta, 1 chorion, 2 amnions, 2 umbilical cords
b. Dizygotic Twins “fraternal twins”
--2 ovum, 2 sperms --2 placentas, 2 chorions, 2 amnions, 2 umbilical cords --same or different sex Manifestations: a. uterine size is greater than expected b. palpation of three or more large parts c. different FHT of different frequencies Complications: a. premature delivery b. hemorrhage c. HPN d. Fetal malpresentation e. Uterine dysfunction due to overstretching f. Cord compression g. Twin-to-twin transfusion syndrome •
Recipient Twin
•
Donor twin
Mgt: a. Prenatal Care b. Balanced diet c. Rest periods d. Anticipatory guidance & support * Rh INCOMPATIBILITY •
Rh (-) mom, Rh (+) baby
1st Pregnancy •no problem • during delivery antigen-antibody reaction •development of antibodies (sensitization) of the mother 2nd Pregnancy: ERYTHROBLASTOSIS FETALIS
Preventive Mgt: a. Blood typing / Rh determination b. Coomb’s test Indirect – mother’s blood Direct – umbilical cord sample c. Rhogam Curative Mgt: 1. Exchange Transfusion umbilical catheter is withdrawn, equal amount of Rh (-) donor blood is transfused procedure is continued until most of the blood is replaced −
−
2. Intrauterine Transfusion 21
a.
b.
c.
d.
2 to 3 hours before the transfusion to begin, 50 ml of radiopaque dye is injected into the amniotic fluid by amniocentesis technique fetus will swallow the amniotic fluid with dye & will be present in the intestine with the aid of sonogram, cannula is inserted into the fetal abdomen & blood O negative will be deposited into the abdomen the RBC will be absorbed across the fetal peritoneum into the circulation
c.
3. Psyche
fear, anxiety & tension increase stress & can decrease uterine contractility stress interferes client’s ability to work with her contractions stress increases fatigue
B. PRECIPITATE DELIVERY characterized by very strong contractions & delivery occurs less than 3 hours of labor
COMPLICATIONS OF LABOR & DELIVERY A. Dystocia
Predisposing Factors: multiparity history of rapid labor premature or small fetus large bony pelvis
1. Power a. Hypertonic Labor Pattern occurrence: characteristics: contractions that are frequent, strong but uncoordinated contractions that are ineffective in accomplishing cervical effacement & dilatation Treatment:
Risks: perineal lacerations hemorrhage cerebral trauma Mgt: fetal monitoring analgesia assess for birth injury assess for cervical vaginal & perineal lacerations
b. Hypotonic Contractions occurrence: characteristics: uterine contractions that are inadequate causes: early analgesia bladder or bladder distention multiple gestation large fetus hydramnios grandmultiparity Treatment:
perform assisted vaginal or caesarean delivery
C. UMBILICAL CORD PROLAPSED
Causes: 1. 2. 3. 4. 5. S/Sx:
1. cord is protruding from vagina 2. cord can be palpated in the vagina or cervix 3. fetal distress
2. Passageway – pelvis contracted uterus unfavorable pelvic shapes Mgt: a. evaluate pelvic diameters b. continue labor with careful monitoring
breech presentation transverse lie unengaged presenting part hydramnios small fetus
Mgt:
1.
T – position or knee chest
22
2. 02 – prevent fetal hypoxia 3. push presenting part upward 4. apply moistened sterile towel 5. delivery ASAP
OBSTETRIC INTERVENTIONS A.
INDUCTION OF LABOR
1.
HPN, pre-eclampsia or eclampsia 2. prolonged ruptured of membrane 3. postmaturity 4. DM Prerequisites: 1. longitudinal lie 2. ripe cervix 3. engaged 4. no CPD – X ray pelvimetry
Indications:
Danger Signs: contractions occur more than q2min 1. contraction duration exceeds 75 – 90 seconds 2. uterine resting tone increase steadily, or uterine relaxation between contractions is insufficient 3. . Contraindications: 1. fetal scalp blood sampling 2. preterm infants B. FORCEP DELIVERY 1 blade is slipped into the woman’s vagina next to fetal D. CAESAREAN DELIVERY head, other is slipped into place on other side of the Indications: head 1. CPD Types: 2. malposition 1. Outlet/Low Forcep 3. malpresentation 2. Midforcep 4. previous CS 3. High Forcep 5. complete or partial placenta previa 6. abruptio placenta 7. prolapsed umbilical cord Purposes: nd 1. to shorten the 2 stage of 8. fetal distress labor Types: 2. prevents excessive 1. Low segment - incision done on lower uterine pounding of the fetal head segment against the perineum - blood loss is minimal 3. prevents exhaustion from - Bikini or Pfannenstiel a woman’s pushing effect 4. speed delivery in fetal 2. Classic - incision is made into the body of the distress uterus (vertical) - done for anterior placenta previa Prerequisites: 1. fully dilated cervix - done for transverse lie fetus 2. ruptured membranes 3. no CPD • Preparation: 4. empty bladder/rectum 1. NPO Indications: 2. Shave or clip pubic hair 1. Woman unable to push with 3. Insert Foley cath contractions 4. Prepare blood 2. Cessation of descent in 2nd stage 5. Signed consent 3. Fetal distress from cord prolapse Nursing Care: 1. monitor V/S closely C. VACUUM EXTRACTION 2. check dressing site an assisted vaginal delivery with the use of 3. inspect perineal pad vacuum (Ventousse) machine 4. check fundus for firmness 5. breathing exercises Indications: nd 1. prolonged 2 stage of labor 6. out of bed 1st post op day 2. fetal distress 7. have the woman hold the baby ASAP 3. maternal distress 23
HYPERTENSIVE DISORDER OF PREGNANCY
P Signs of fetal distress Serum Mg level greater than 2.5 mEq/L ANTIDOTE:
PIH (Pregnancy Induced Hypertension )
•
Risk Factors: primiparas younger than 18 or older – than 35 multipara – multiple gestation – family history – Predisposing Fx: low socio-economic status ( poor – nutrition ) underlying disease ( heart disease, – diabetes, chronic hypertension )
2. Eclampsia a. adm O2 b. bed rest - absolute bed rest - side-lying to drain secretions - private room, darkened and quiet – near nurse’s station - no external stimuli - no visitors c. external fetal monitor d. MgSO4 or diazepam e. termination of pregnancy
Manifestations: 1. Mild Pre-Eclampsia increase systole 30 mmHg increase diastole 15 mm Hg mild edema of hands & face proteinuria 1-2+ wt. gain of 2 lb/wk in 2nd trimester 1 lb/wk in 3rd trimester 2. Severe Pre-Eclampsia BP 160/110 mmHg noted on 2 readings at least 6hrs apart Proteinuria ( 3-4+ ) Pitting edema; generalized Oliguria Severe epigastric pain Nausea, vomiting Visual disturbances Severe headache Hyperreflexia
CARDIAC DISEASE Classifications: Class I – Asymptomatic with all activity Class II – Asymptomatic @ rest; symptomatic with heavy physical activity Class III – Asymptomatic @ rest, symptomatic with ordinary activity Class IV – Symptomatic with all activity, symptomatic with rest
•
• • • •
Effects on the Fetus: a. retarded growth b. fetal distress c. premature labor
• • • •
3. Eclampsia presence of convulsions coma cerebral hemorrhage, liver rupture blurring of vision, severe headache (increased cerebral edema) hyperactive reflexes
Mgt: Goal= to reduce workload of the heart
1. Promote rest 2. Promote a healthy diet 3. Educate regarding meds a. Digitalis may be given
Management:
to increase 1. Mild/Severe Pre-Eclampsia a. bedrest in side lying position b. quiet & calm environment c. monitor fetal/maternal well being d. good nutrition e. administer meds Hydralazine (Apresoline )
contractility of the heart b. Penicillin may be
given to prevent endocarditis 4. Educate regarding avoidance of
•
infection •
MgSO4 (drug of choice)
5. Promote reduction of psychologic -
stress
toxic signs
B U R
6. Deliver TORCH INFECTIONS
24
Oppurtunistic infxns: Pneumocystis carinii pneumonia Kaposi’s sarcoma HIV-assoc dementia –
TOXOPLASMOSIS - CA: - MOT: eating undercooked meat • contact with cat stool or litter • other carriers of the organism include dogs, • cattle, goats & birds - S/Sx: Fatigue • Muscle pains • Lympadenopathy • - Fetal Effects: Abortion • Low birth weight • Blindness, Deafness • CNS damage ( Mental Retardation, convulsions • ) - Treatment:
OTHERS HIV, Gonorrhea, HPV, Chickenpox, Hepa B HIV-AIDS
- CA
• • •
- Therapeutic Mgt: 1. DOC: a. Zidovudine (ZVD) antiviral • helps reduce mother-to-fetal • transmission 100mg PO 5x per day from 14th wk • gest-labor (IV) NB: 2mg/kg q6hrs for 6wks • b. Sulfamethazone-Trimethoprim (Bactrim) c. Pentamidine (Pentam) 2. Contact precautions 3. Contraindications: - amniocentesis - creation of source of bleeding (episiotomy, forceps delivery) - breastfeeding 4.Optimal nutrition & healthy lifestyle - Fetal effects: Prematurity • Low birth weight • Fetal demise •
- Mode of Transmission: a. b. c. d. -DX: --HIV Antibody Test ELISA (Enzyme linked Immunoassay) • Western Blot (WB) assay • confirmatory test – Indirect Immunofluorescence assay (IFA) •
GONORRHEA - CA: - MOT: - S/Sx: •
Female - asymptomatic - yellow-green vaginal discharge
Male - burning on urination - urinary frequency - purulent penile discharge (yellow or green) - Dx: a. culture b. gram stain -Mgt: DOC a. Ceftriaxone b. Doxycycline c. Cefixime (Suprax) – •
3
--CD4 cell count below 500 cells/mm = risk for opportunistic infxns 200 cells/mm3 = + infxns - S/Sx: a. Initial HIV infection (mild, flulike) fatigue – fever – enlarged lymph nodes – rash – b. Seroconversion = c. Asymptomatic = AIDS related complex weight loss – malaise – CNS dysfunction – Fever – Lymphadenopathy – d. Symptomatic = 7-10 yrs •
-Fetal Effects: OPHTHALMIA NEONATORUM Crede’s prophylaxis given – -Maternal Complications: --preterm birth --spontaneous miscarriage --endometritis 25
--PID S/Sx: HUMAN PAPILLOMA VIRUS -CA: - causes fibrous tissue overgrowth on external vulva - S/Sx: Cauliflower-like lesions Foul vulvar odor - Management: DOC: podophyllum (Podofin) = Trichloroacetic acid (TCA) = • •
•
•
• •
Removal of lesions: laser tx, cryocautery Sitz bath & lidocaine CS if obstructing birth canal
Candidiasis -CA: -S/Sx: a. cream cheese like vaginal discharge b. dyspareunia c. itchiness & reddening of the vulva -Mgt: a. 1% gentian violet b. Nystatin suppository c. miconazole (Monistat) – antifungal cream for 7days - Fetal Effects: “thrush” or oral candidiasis • acquired by the baby as it passes – through the infected vagina
a. frothy yellow,greenish or grayish vaginal discharge b. erythematous vagina “strawberry” c. foul odor Mgt: • a. Metronidazole (Flagyl) given in non pregnant women b. Vaginal douching diluted vinegar solution or betadine • Maternal Complications: -preterm labor -premature rupture of membranes -post cesarean infection Chlamydia
CA: Chlamydia Trachomatis - S/Sx: a. thin to thick, clear to cloudy vaginal discharge b. dyspareunia c. dysuria d. friable cervix –
RUBELLA [GERMAN MEASLES]
• • •
Trichomoniasis cataracts • deafness • CNS defects • cardiac defects • facial clefts • Low birth weight • Anemia • Jaundice •
-CA: -MOT: -S/Sx: mild systemic infection fever rash lymphedema -Fetal Effects:
26
- Prevention: Vaccination – all women of childbearing age • pregnant women cannot be immunized • women who have been vaccinated should not • get pregnant for 3 months •
•
As duration of pregnancy increases fetal infections are less likely to cause congenital malformations Infants with congenital Rubella shed virus for many months thus a threat to other infants
CYTOMEGALY Inclusion Disease -CA: -MOT: -S/Sx: Asymptomatic Mononucleosis like syndrome: - Dx: -Mgt: no vaccine – Educate – Counselling – No breastfeeding – • •
Herpes Simplex II (Herpes Genitalia) -CA: -MOT: sexually transmitted • skin-to-skin contact •
--S/Sx: -painful pinpoint vesicles -fever -malaise -dyspareunia • Fetal Effects: -Hydrocephalus -Growth retardation -Eye damage -“blueberry-muffin” lesions •
1. 2. 3. 4. 5.
Mgt: Acyclovir (Zovirax) – 36 wks AOG Handwashing Avoid contact between lesions, her hand and baby C-Section Breastfeeding is allowed
Syphilis -CA: -MOT: Stages:
a. Primary- chancre (painless lesion) – disappears after 2-6 wks b. Secondary – 2-12 wks after first exposure
- condylomata lata = flattened, moist, wartlike lesions - bronze or rose-colored rash - headache - sore throat - spotty loss of hair - enlarged lymph nodes c. Latent - detected thru serology VDRL – antigen-antibody rxn test • FTA-ABS – specific antibody test for syphilis • d. Tertiary widespread serious disorder of the heart, brain, CNS, liver, bones Gumma = mass of dead and swollen fiber like tissues -Mgt: DOC: Benzathine Penicillin G • -- Jarisch-Herxheimer Reaction: caused by sudden destruction of spirochetes & last about 24hrs -- sudden episode of hypotension, fever, tachycardia & muscle aches Fetal Effects: • a. abortion b. stillbirth c. congenital syphilis Hutchinson’s teeth – Saddle nose – Blisters & peeling skin over hands & – soles of feet Fissures around hips & anus – Snuffles – thick, blood-tinged nasal – discharge assoc. with a sniffing sound on respiration
TO GOD BE THE GLORY! (AD MAJOREM DEI GLORIAM)
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