FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY

I.

The External Reproductive Organ (Figure 1) a. Mons Pubis or Veneris pad of fats which lies over the symphysis pubis covered by skin and at puberty, by short hairs, protects the surrounding delicate tissues from trauma. b. Labia Majora Two folds of skin with fat underneath: contain Bartholin glands (believed to secrete a yellowish mucus which acts as a lubricant during sexual intercourse). The openings of the Bartholins glands are located posteriorly on either side of the two vaginal orifice. c. Labia Minora two thin folds of delicate tissues: for an upper fold encircling the clitoris (called forchette, which is highly sensitive to manipulation and trauma that is why it is often torn during womens delivery). d. Glans Clitoris small, erectile structure at the anterior junction of the labia minora, which is comparable to the penis in its being extremely sensitive. e. Vestibule narrow space seen when the labia minora are separated. f. Urethral Meatus external opening of the urethra: slightly behind and to the side are the openings of the Skene glands (which are often involved in infections of the external genitalia). g. Vaginal orifice/Introitus External opening of the vagina, covered by a thin membrane (called hymen) in virgins. h. Perineus area from the lower border of the vaginal orifice to the anus; contains the muscles (e.g., pubococcygels and levator ani) which support the pelvic organs, the arteries that supply blood and the pudendal nerves which are important during delivery under anesthesia. The Internal Reproductive Organs (Figure 2) a. Vagina a 3-4 inch long dilatable canal located between the bladder and the rectum; contains rogue, (which permit considerable stretching without tearing): passageway for menstrual discharges, copulation and fetus. b. Uterus hollow pear-shaped fibromuscular organ. 3 inches long, 2 inches wide, 1 inch thick, and weighing 50 60 grams in a non-pregnant woman held in place by broad ligaments from sides of the uterus to pelvic walls; also hold Fallopian tubes and ovaries in place) and round ligaments (from sides of uterus to mons pubis); abundant blood supply from uterine and ovarian arteries; composed of 3 muscle layers (perimetrium, ayometrium, and endometrium). Consists of three parts: corpus (body) upper portion with triangular part called fundus; isthmus area between corpus and cervix which forms part of the lower uterine segment; and cervix lower cylindrical portion. (1) Organ of menstruation, (2) site of implantation and (3) retainment and nourishment of the products of conception. c. Fallopian Tubes 4 inches long from side of the fundus; widest part (called empala) spreads into fingerlike projections (called pimbrige). Responsible for transport of mature ovum from ovary to uterus; fertilization takes place in its outer third or outer half. d. Ovaries almond-shaped, dull white sex glands near the fimbriae, kept in place by ligaments. Produce, mature and expel ova and manufacture estrogen and progesterone. The Pelvis (Figure 3) although not a part of the female reproductive organs but of the skeletal system. Is the very important body part of pregnant woman. A. Structure 1. 2 Os Coxae/Innominate bones made up of a. Ilium upper, extended part; curved upper border is the Illiac crest. b. Ischium under part; when sitting, the body rests on the ischial tuberositis: ischial spines are important landmarks. c. Pubis front part; join to form an articulation of the pelvis called the symphysis pubis.

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III.

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Sacrum wedge-shaped, forms at the back part of the pelvis. Consists of 5 fuse vertebrae, the first having a prominent upper margin called the sacral promontory. Articulates the ilium, the sacroiliac joint. Coccyx lowest part of the spine; degree of movement between sacrum and coccyx, made possible by the third articulation of the pelvis called sacroccygeal joint which allows room for delivery of the fetal head.

3.

B.

Divisions set apart by the linea terminalis, an imaginary line from the sacral promontory to the iliac on both sides to the superior portion of the symphysis pubis. 1. False pelvis superior half-formed by the iliac. Offers landmarks for pelvic measurements; supports the growing uterus during pregnancy; and directs the fetus into the true pelvis near the end of gestation. 2. True pelvis inferior half formed by the pubis in front, the iliac and the ischium on the sides, and the sacrum and coccyx behind. Made up of three parts: a. inlet entranceway to the true pelvis. Its transverse diameter id wider than its anteroposterior diameter. Transverse diameter 13.5 cm Anteroposterior diameter 11 cm Right and left oblique diameter 12.75 cm. b. Cavity space between the inlet and outlet c. Types/variations 1. Gynecoid normal female pelvis. Inlet is well rounded forward and back. Most ideal for childbirth. 2. Anthropoid transverse diameter is narrow, AP diameter is larger than normal. 3. Platypelloid inlet is oval, AP diameter is shallow. 4. Android male pelvis. Inlet has a narrow, shallow posterior portion and pointed anterior portion. d. Measurements 1. External suggestive only of pelvic size. a. Intercristal distance between the middle points of the iliac crests. Average 28 cm. b. Interspincus distance between the anterosuperior iliac spines. Average 25 cm. c. Intertrochanteric distance between the trochanters of the femus. Average 31 cm. d. External conjugate/baudelocques the distance between the anterior aspect of the symphysis pubis and depression below Ls. Average 18-20 cm. 2. Internal give the actual diameter of the inlet and outlet. a. Diagonal conjugate distance between sacral promontory and inferior margin of the symphysis pubis. Average 12.5 cm. b. True conjugate/conjugata vera distance between the anterior surface of the sacral promontory and the superior margin of the symphysis pubis. Very important measurement because it is the diameter of the pelvic inlet. Average 10.5-11 cm. c. Bi-schial diameter/tuberishii transverse diameter of the pelvic outlet. Is measured at the level of the anus. Average 11 cm.

IV. A.

Mechanism of Menstruation General Considerations

1.

2.

300,000 4000,000 immature cocytes per ovary are present at birth (where formed during the first 5 months of intrauterine life), many, however, degenerate and atrophy (process called atresia). About 300 400 mature during the entire reproductive cycle of women. Ushered in by Menarche, (first menstruation in girls) and ends with menopause (permanent cessation of menstruation; no more functioning cocytes in the ovaries). Age of onset and termination varies widely, depending on heredity, racial background, nutrition and climate. Normal period (days when there is menstrual flow) last for 3 6 days; menstrual cycle from first day of menstrual period to the first day next menstrual period. Average menstrual cycle 24-36 days to 28 days acceptable. An ovulatory states after menarche not unusual because of immaturity of feedback mechanism. a. Pregnancy b. Lactation c. Related disease conditions Associated terms: a. Amenorrhea temporary cessation of menstrual flow. b. Oligomenorrhea markedly diminished menstrual flow, nearing amenorrhea. c. Menorrhagia excessive bleeding during regular menstruation. d. Metrorrhagia bleeding at completely irregular intervals. e. Polymenorrhea frequent menstruation occurring at intervals of less than 3 weeks. Body structures involved: a. Hypothalamus b. Anterior pituitary gland c. Ovary d. Uterus Hormones which regulates cyclic activities: a. Follicle Stimulating Hormone (FSH) b. Luteinizing Hormone Effects of estrogen in the body a. Inhibits production of FSH b. Causes hypertrophy of the myometrium c. Stimulates growth of the ductile structures of the breasts. d. Increases quantity and pH of cervical mucus, causing it to become thin and watery and can be stretched to a distance of 10 13 cm. (Spinnbarkheit test of ovulation). Effects of progesterone in the body: a. Inhibits production of LH b. Increases endometrial tortuosity c. Increases endometrial secretions d. Inhibits uterine motility e. Decreases muscle tone of gastrointestinal and urinary tracts f. Increases musculoskeletal motility g. Facilitates transport of the fertilized ovum through the fallopian tubes h. Decreases renal threshold for lactose and dextrose i. Increases fibrinogen levels; decreases hemoglobin and hematocrit j. Increases body temperature after ovulation. Just before ovulation, basal body temperature decreases slightly (because of low of progesterone level in the blood) and then increases slightly a day after ovulation (because of the presence of progesterone).

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B.

Sequential Steps in the Menstrual Cycle

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2. 3.

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6. 7. 8.

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10.

On the third day of the menstrual cycle, serum estrogen level serve is at its lowest. This low estrogen level serves as the stimulus for the hypothalamus to produce Follicle Stimulating Hormone Releasing Factor (FSHRF). FSHRF is responsible for stimulating the Anterior Pituitary Gland (APG) to produce the first of two hormones that regulate cyclic activities, the FHS. FSHRF, in turn will stimulate the growth of an immature cocyte inside a primordial follicle by stimulating production of estrogen by the ovary. once estrogen is produced, the primordial follicle is now termed Graafian follicle. (The Graafian follicle, therefore, is the structure that contains high amounts of estrogen). Estrogen in the Graafian follicle will cause the cells in the uterine endothelium to proliferate (grow very rapidly), thereby increasing its thickness to about eight folds. This particular phase in the uterine cycle, therefore, 13 called proliferative phase. In view of the change from primordial to Graafian follicle, it is also called the follicular phase. Because of the predominance of estrogen, it is also called the estrogenic phase. and since it comes right after the menstrual period, it is also called postmenstrual phase. And it is also called pre-ovulatory phase. On the 13th day of the menstrual cycle, there is now a very low level of progesterone in the blood. This low serum progesterone level is then the stimulus for the hypothalamus to produce the Luteinizing Hormone Releasing Factor (LHRF). LHRF is responsible for stimulating the APG to produce the second hormone that regulates cyclic activity, the Luteinizing Hormone (LH). LH, in turn, is responsible for stimulating the ovary to produce the second hormone produced by the ovaries, progesterone. The increase amount of both estrogen and progesterone pushes the new mature ovum to the surface of the ovary until, on the following day (14th day of the menstrual cycle), the Graafian follicle ruptures and releases the mature ovum, and a process called ovulation. Once ovulation has taken place, the Graafian follicle, because it now contains increasing amounts of progesterone, giving it its yellowish appearance is termed Corpus Luteum. (Therefore, the structure which contains high amounts of progesterone in the Corpus Luteum). Progesterone causes the glands of the uterine endothelium to become corkscrew or twisted in appearance because of the increasing amount of capillaries. Progesterone therefore, is said to be the hormone designed to promote pregnancy because it makes the uterus nutritionally abundant with blood in order for the fertilized zygote to survive should conception take place. That is why this phase in the uterine cycle is what we call progesterone phase. This phase in the uterine cycle is also called secretory phase because it secretes the most important hormone in pregnancy. In view of the change from Graafian follicle to Corpus Luteum, it is also called the Luteal phase. because it occurs the post-ovulatory phase. And, it is also called pre-menstrual phase. Up until the 24th day of the menstrual cycle, if the mature ovum is not fertilized by a sperm, the amounts of hormones in the Corpus Luteum will start to decrease. The Corpus Luteum turning white, is not called the corpus alhisans and after 3-4 days, the thickened lining of the uterus produced by estrogen starts to degenerate and sloughs off and the capillaries capture. And thus being another menstrual period.

11.

C.

Additional Information 1. When the ovary releases the mature ovum on the day of ovulation, sometimes a certain degree of pain in either the right or left lower quadrant is felt by the woman. This sensation is normal and termed mittelschmerz. 2. The first 14 days of the menstrual cycle is a very variable period. The last 14 days of the menstrual cycle is a fixed period exactly 2 weeks after ovulation, menstruation will occur (unless a pregnancy had taken place) because the corpus luteum has a life span of only 2 weeks. Implication: when giving options regarding the exact date of ovulation, choose two weeks before menstruation. 3. In a 28-day cycle, ovulation takes place on the 14th day. In a 32-day cycle, ovulation takes place on the 18th day. In a 26-day cycle, ovulation takes place on the 12th day (subtract 14 days from the cycle).
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Menstruation can occur even without ovulation (as in women taking oral contraceptives). Ovulation can likewise occur even without menstruation (as in lactating mothers). PREGNANCY AND PRENATAL CARE

I.

Obstetric Terms in Statistical Data A B. C. D. E. F. Birth rate the number of birth per 1000 population. Fetal death rate the number of total deaths per 1000 births (both live births and stillbirths) Perinatal mortality rate the number of deaths occurring between 28 weeks of gestation until 6 days after birth. Neonatal mortality rate the number of neonatal (first 28 days of life) deaths per 1000 live births. Infant mortality rate the number of infant (first 12 months of life; death per 1000 live births. Maternal mortality rate the number of deaths that occur as the direct result of the reproductive process per 10,000 live births

II.

Fertilization A. Definition: The union of the sperm and the mature ovum in the outer haft of the fallopian tube. B. General Considerations: 1. Normal amount of semen per ejaculation 3-5 cc = 1 teaspoon 2. Number of sperms in an ejaculate 120-180 million/cc 3. Mature ovum is capable of being fertilized for 12-24 hours after ovulation. Sperms are capable of fertilizing even for 3-4 days after ejaculation. 4. Normal life span of sperms = 72 hours 5. Sperms, once deposited in the vagina, will generally reach the cervix within 90 seconds after deposition. 6. Reproductive cells, during gametogenosis, divide by meiosis (haploid number of daughter cells): therefore, they contain only 23 chromosomes (the rest of the body cells have 46 chromosomes). Sperms have 22 autosomes and 1 X sex chromosome or 1 Y sex chromosome; ova contain 22 autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a mature ovum results in a baby girl (XX); the union of a Y-carrying sperm and a mature ovum results in a baby boy (XY). IMPORTANT: Only fathers determine the sex of their children. Implantation Immediately after fertilization, the fertilized ovum or zygote stays in the fallopian tube for 3 days, during which time rapid cell division (mitosis) is taking place. The developing cells are now called Blastomere and when there are already 16 blastomeres, it is now termed morula. In this morula form, it will start to travel (by ciliary action and peristaltic contractions of the fallopian tube) to the uterus where it will stay for another 3-4 days. When there is already a cavity formed in the morula, it is now called a blastocyst. Fingerlike projections, called trophoblasts, form around the blastocyst and these trophoblasts are the ones which will implant high on the anterior or posterior surface of the uterus. Thus, implantation, also called nidation takes place about a week after fertilization.

III.

GENERAL CONSIDERATION: A. B. Once implantation has taken place, the uterine endothelium is now termed Desidua. Occasionally a small amount of vaginal spotting appears with implantation because capillaries are ruptured by the implanting trophoblasts = implantation bleeding. Implication: this should not be mistaken for the Last Menstrual Period (LMP).
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Table 1. Outline of Trophoblast Differentiation I. II. Cytotrophoblast the inner layer Syncytiotrophoblast the outer layer containing fingerlike projection called chorionic villi: A. Langhans layer believed to protect the fetus against Treponema Pallidum (etiologic agent of syphillis). Present only during the second trimester of pregnancy. B. Syncytial layer gives rise to the fetal membranes: 1. Amnion inner layer which gives rise to: a. Umbilical cord/funis contains 2 arteries and 1 vein, which are supported by the Whartons jelly. b. Amniotic fluid clear, albuminous fluid in which the body floats. Begins to form at 11-15 weeks gestation. Approximate water in specific gravity (1.007-1.025) and is neutral to slightly alkaline (pH = 7.0-7.24. Note: the higher the pH, the more alkaline; the lower the pH, the more acidic). Near term, is clear, colorless, containing little white specks of vernix caseosa and other solid particles. Produced at a rate of 500 ml in 24 hours and fetus swallows it at an equally rapid rate. By the 14th lunar month, urine is added to the amount of amniotic fluid. It is, therefore, derived chiefly from maternal serum and fetal urine. (Implication: a case of polyhydranios = more than 1500 ml of amniotic fluid, stems from inability of the fetus to swallow amniotic rapidly, as in Tracheoesophageal fistula; while oligohydramnios = amniotic fluid less than functioning normally, as in congenital renal anomaly). Also known as Bag of Water (BOW), it serves the following purposes: *. Protection: Shields the fetus against blows or pressure on the mothers abdomen. Protects the fetus against sudden changes in temperature because liquid changes temperature more slowly than air. Protects the fetus against certain infections Diagnosis: As in amniocentesis Mecomium-stained amniotic fluid means fetal distress 2. Chorion together with the decidua basalis gives rise to the placenta, which starts to form on the 8th week of gestation. Develops into 15-20 subdivision called cotyledons. Placenta serves the following purposes: a. Respiratory system exchange of gases takes place in the placenta, not in the fetal lungs. b. Renal system waste products are being excreted through the placenta (Note: it is the mothers liver which detoxifies the fetal waste products). c. Gastrointestinal system nutrients pass to the fetus via the placenta by diffusion through the placental tissues. d. Circulatory system feto-placental circulation is established by selective osmosis. e. Endocrine system it produces the following hormones (before 8 weeks gestation, the corpus luteum is the one producing these hormones): Human Chorionic Gonadotropin (HCG) orders the corpus luteum to keep on producing estrogen and progesterone that is why menstruation
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does not take place during pregnancy test. It is also called the basis of pregnancy test. Human Placental Lactogen (HPL)/human chorionic somatomammotropin promotes growth stimulating properties. Estrogen progesterone Protective barrier inhibits passage of some bacteria and large molecules

Stages of Prenatal Development: a. fertilization b. first 12-14 days = zygote c. from 15th day up to the 8th week = embryo d. from 8th week up to the time of birth = fetus IV. Fetal Development A. First Lunar Month 1. Germ layers differentiate by the 2nd week (In cases of multiple congenital anomalies, the structures that will be affected are those that arise out of the same germ layer). a. Endoderm develops into the lining of the GIT, the respiratory tract, tonsils, thyroid (for basal metabolism), parathyroid (for calcium metabolism), thymus gland (for development of immunity), bladder and urethra. b. Mesoderm forms into the supporting structures of the body (connective tissues, bones, cartilage, muscles and tendons), heart, circulatory system, blood cells, reproductive system, kidneys and ureters. c. Ectoderm responsible for the formation of the nervous system, the skin, hair and nails, the sense organs and mucus membrane of the anus and mouth. 2. Fetal membranes (Amnion and chorion) appear by the second week. 3. Nervous system very rapidly develops by the third week (dizziness is said to be the earliest sign of pregnancy because as the fetal brain rapidly develops, glucose stores of the mother are depleted, thus causing hypoglycemia in the latter). 4. Fetal heart begins to form as early as the 16th day of the life (to the question, When does the fetal heart begin to beat?, the answer is the first lunar month. But to the question. When can fetal heart tones be first heard?, the answer is fifth month.) 5. The digestive and respiratory tracts exist as a single tube until the third week of life when they start to separate. Second Lunar Month 1. All vital organs are formed by the end of the 8th week. 2. Placenta develops fully. 3. Sex organs (ovaries and testes) are formed by the 8th week. (to the question, when is sex determined?, the answer is at the time of conception.) 4. Meconium (first stools) is formed in the intestines by the 5th to 8th week. Third Lunar Month 1. Kidneys are able to function urine formed by the 12th week. 2. Buds of milk teeth form. 3. Beginning bone ossification. 4. Fetus swallows amniotic fluid. 5. Feto-placenta circulation is established by selective osmosis; no direct exchange between fetal and maternal blood. Fourth Lunar Month 1. Lanugo appears
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Buds of permanent teeth form Heart beats are audible with fetoscope

Fifth Lunar Month 1. Vernix caseosa appears 2. Lanugo covers entire body 3. Quickening (fetal movements) felt 4. Fetal heart beats very audible Sixth Lunar Month 1. Skin markedly wrinkled 2. Attains proportions of full term baby Seventh Lunar Month 1. Alveion begin to form (28th weeks gestation is said to be the lower limit of prematurity; if born, cries breath, but usually dies). Eight Lunar Month 1. fetus is viable 2. lanugo begins to disappear 3. nails extend to ends of fingers 4. subcutaneous fat deposition begins Ninth Lunar Month 1. Lanugo and vernix disappear 2. Amniotic fluid volume somewhat decreases Tenth Lunar Month all characteristics of the normal new born

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J. V.

Focus of Fetal development A. First Trimester organogenesis B. Second trimester period of continued fetal growth and development: rapid increase in fetal length C. Third trimester period of most rapid growth and development because of rapid deposition of subcutaneous fat. Normal Adaptation in Pregnancy A. 1. Systemic changes Circulatory/Cardiovascular A. Beginning the end of the first trimester, there is gradual increases of about 30% - 50% in total cardiac volume, reaching its peak during the six month period. This causes a drop in hemoglobin and hematocrit values since the increas is only in the plasma volume = physiologic anemia of pregnancy. Consequences of increased total cardiac volume are: Easy fatigability and shortness of breath because of increased workload of the heart Slight hypertophy of the heart, causing it to be displace to the left, resulting in torsion on the great vessels (the aorta and pulmonary artery) Systolic murmurs are common due to lowered blood viscosity Nose bleeds may occur because of marked congestion of the nasopharynx as pregnancy progresses. B. Palpitation due to: Sympathetic nervous system stimulation during first half of pregnancy Increased pressure of uterus against the diaphragm during second half of pregnancy
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D.

Because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities: Edema of the lower extremities occurs. Management: raise legs above the level. Important: edema of the lower extremities is not a sign of toxemia. Varicosities of the lower extremities can also occur. Management: Use/wear support hose or elastic stocking to permit venous flow. Thus preventing static in lower extremities. Apply elastic bandage start at the distal end of the extremity and work toward the trunk to avoid congestion and impaired circulation in the distal part; do not wrap toes so as to be able to determine the adequacy of circulation (principle behind bandaging: blood flow to tissues is decreased by applying excessive pressure on blood vessels). Avoid use of constricting garters, e.g. knee-high socks

Because of poor circulation in the blood vessels of the genitalia due to pressure of the gravid uterus, varicosities of the rectum and vulva can occur. Management: side-lying position with hips elevated on pillows Advise modified knee-chest position E. There is increased level of circulating fibrinogen, that is why pregnant women are normally safeguarded against undue bleeding. However, this also predisposes them to formation of blood clots (thrombi). The implication is that pregnant women should not be massaged since blood clots can released and cause thromboembolism.

2.

Gastrointestinal Changes a. Morning sickness (Nausea and vomiting during the first trimester) is due to increased Human Chorionic Genadotropin (HCG). It may also be due to increased acidity or even to emotional factors. Management: Eat dry toast or crackers 30 minutes before arising in the morning (or dry carbohydrate, low fat and low spices In the diet). Hyperemesis gravidarum = excessive nausea and vomiting which persists beyond 3 months; will result in dehydration,starvation and acidosis, Management: D10NSC 3000 ml in 24 hours is the priority of treatment Complete bed rest is also important aspect of treatment. Constipation and flatulence are due to the displacement of the stomach and intestines, thus slowing peristalsis and gastric emptying time; may also be due to increased progesterone during pregnancy. Management: Increased fluid and roughage In the diet Establish regular elimination time Increase exercise Avoid enemas Avoid harsh laxatives like Duleolax: stool softeners, e.g., Colace, are better Mineral oil should not be taken because it interferes with absorption of fat soluble vitamins. Hemorrhoids are due to pressure of enlarge uterus. Management: cold compress with witon hazel or Epson salts Heartburn, especially during the last trimester, is due to increased progesterone which decreases gastric motility, thereby causing reverse peristaltic waves which lead to regurgitaton of stomach contents through the cardiac sphyncter into the esophagus, causing irritation.
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Management: Pats of butter before meals Avoid fried, fatty foods Sips of milk at frequent intervals Small frequent meals taken slowly Bend at the knees, not at the waist Take antacids (e.g., milk of magnesia) but NEVER Sodium Bicarbonate (e.g., Alka Seltzer or Baking soda) because it promotes fluid retention 3. Respiratory Changes there is shortness of breath A. Causes: Increased oxygen consumption and production of carbon dioxide during the first trimester Increased uterine size causes diaphragm to be pushed or displaced, thus crowding chest cavity B. Management: lateral expansion of the chest to compensate for shortness of breath increases oxygen supply and vital lung capacity. Urinary Changes A. Urinary frequency, the only sign in pregnancy seen during the first trimester, disappear during the third trimester. Early in pregnancy is due to increased blood supply in the kidneys and to the uterus rising up of pelvic cavity; on the last trimester, is due to pressure of enlarged uterus on the bladder, especially with lightening. B. Decreased rema, threshold for sugar due to increased production of glucoccorticoids which cause lactus and dextrose to spill into the urine; also an effect of the increase in progesterone. (implication: it would be difficult to diagnose diabetes in pregnancy based on the urine sample alone because of all pregnant women have sugar in their urine). Musculoskeletal Changes A. Because of the pregnant womens attempt to change her center of cavity, she makes ambulation easier by standing more straight and taller, resulting in a lordotic position ((pride of pregnancy) B. Due to increased production of the hormone relaxin, pelvic bone become more supple and movable, increasing the incidence of accidental falls due to the wobbly gait. Implication: Advise use of low hosted shoes after the first trimester. C. Leg cramps are caused by: Increased pressure of gravid uterus on lower extremities Fatigue Chills Muscle tenseness Low calcium, high phosphorus intake Management: Frequent rest periods with feet elevated Wear warm, more comfortable clothing Increase calcium intake (calcium tablets and diet) Do not massage blood clots can cause embolism Most effective relief: Press knee of the affected leg and dorsiflex the foot Temperature slight increase in body temperature due to increased progesterone, but the body adapts after the fourth month. Endocrine Changes A. Addition of the placenta as an endocrine organ, producing large amount of estrogen, progesterone, HCT & HPL.
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Moderate enlargement of the thyroid gland due to hyperlasia of the glandular tissues and increase vascularity. Could also be due to increased basal metabolic rate to as much as +25% because of the metabolic activity of the products of conception. Increased size of the parathyroids, probably to satisfy the increased need of the fetus for calcium. Increased size and activity of the adrenal cortex, thus increasing the amount of circulating cortisol, aldosterone and EDH, all of which affect carbohydrate and fat metabolism Gradual increase in insulin in production but the bodys sensitivity to insulin is decreased during pregnancy.

9.

Weight A. During first trimester, weight gain of 1.5 to 3 lbs. B. On second and third trimesters, weight gain of 10-11 lbs./trimester is recommended. C. Total allowable weight gain during entire period of pregnancy is 20-25 lbs. (=10-12 kg). D. Pattern of weight gains is more important than the amount of weight gained. E. Distribution of weight gain during pregnancy: Fetus 7 lbs. Placenta 1 lb. Amniotic fluid 1 lbs. Increased weight of uterus 2 lbs. Increased blood volume 1 lb. Increased weight of the breasts 1 - 3 lbs. Weight of additional fluid 2 lbs. Fat & fluid accumulation Characteristic of pregnancy 4 6 lbs. TOTAL 20 25 LBS. Emotional Responses A. First trimester: the fetus is unidentified concept with great future implications but without tangible evidence of reality. Some degree of projection, denial and disbelief even repression. (implication: when giving health teachings, be sure to emphasize the bodily changes in pregnancy). B. Second trimester: fetus is perceived as a separate entity. Fantasize appearance of the baby. C. Third trimester: has personal identification with a real baby about to be born and realistic plans for future child care responsibilities. Best time to talk about preparation of layette and infant feeding method. Fear of death, though, is prominent (to allay fears, let pregnant woman listen to the fetal heart tones). Local Changes Uterus a. Weight increases about 1000 grams at full term: due to increased in the amount of fibrous and elastic tissues. b. Change in shape from pear-like to avoid uterine segment causes extreme softening, known as Hegars sign, seen at about the 6th week. c. Mucous plugs in the cervix, calledoperculum, are produced to seal out bacteria. d. Cervix becomes more vascular and edematous, resembling the consistency of an earlobe, known as Gendells sign Vagina a. Increased vascularity causes change in color from light pink to deep purple or violet, known as Chadwicks sign To prevent confusion as to pregnancy signs, arrange the body parts from out to in and the different signs alphabetically. Thus: Vagina Chadwicks sign
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Cervix Goodells sign Uterus Hegars sign Due to increased estrogen, activity of the epithelial cells increases, this increasing amount of vaginal discharges called leukorrhea. As long as the discharges are not excessive, green/yellow in color, foul-smelling or irritatingly itchy, it is normal Management: Maintain or increase cleanliness by taking twice daily shower baths using cool water. pH of vagina changes from the normally acidic (because of the presence of the Doderlein bacilli) to alkaline (because of increased estrogen). Alkaline vaginal environment is supposed to protect against bactrial infection, however, there are two microorganisms which love to thrive in an alkaline environment: Trichomonas, a protozoa or flagellate. The conditon is called trichomonas vaginalis or trichomoniasis. Symptoms: Frothy, cream-colored, irritatingly itchy, foul smelling discharges Vulvar edema and hyperemia due to irritation from the discharges. Treatment: Flagyl for 10 days P.O. or vaginal suppositories of trichomonicidal compounds (e.g., Tricofuron, Vagisec, Devegan), Note: Is carcinogenic during the first trimester. Treat male partner also with Flagyl. Important: avoid alcoholic drinks when taking Flagyl can cause antabuse-like reactions: (vomiting, flushed face and abdominal cramps). Dark brown urine a minor side effect no need to discontinue the drug acidic vaginal douche (1 tablespoon white vinegar in 1 quart of water or 15 ml white vinegar in (1000 ml water) to counteract alkaline preferred environment of the protozoa. Avoid intercourse to prevent reinfection. Monilia, a fungus called candida albicans. The condition is called Moniliasis or Candidiasis. Fungus also loves to thrive in environment rich in carbohydrates (that is why it is common among poorly-controlleddiabetics) and in those on steroid or antibiotic therapy when acidic environment is altered. Symptoms: White, patchy, cheese-like particles that adheres to vaginal walls. Irritatingly itchy and foul smelling vaginal discharges Treatment: Mycostatin/Nystatin p.o. or vaginal suppositories (100,000 U) twice daily for 15 days. Gentian violet swab to vagina (use panty shields to prevent staining of clothes or underwear) Correct diabetes Avoid intercourse Acidic vaginal douche Moniliasis is seen as oral thrush in the newborn when transmitted during delivery through the birth canal of the infected mother.

3.

Abdominal Wall a. Striae gravidarium increased utrine size results in rupture and atrophy of the connective tissue layers, seen as pink or reddish streaks (gently rubbing oil on the skin helps prevent diastasis) b. Umbilicus pushed out Skin a. Linea nigra brown line running from umbilicus to symphisis pubis.
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b. c. 5.

Melasma or Chloasma extra pigmentation on cheecks and across the nose due to the pituitary gland. Sweat glands unduly activated.

Breast a. All changes due to increased estrogen. b. Increase in the size due to hyperplasia of mammary alveoli and fat deposits. Proper breast support with well-fitting brassiere necessary to prevent sagging. c. Feeling of fullness and tingling sensation in the breast. d. Nipples more erect (for mothers who intend to breastfeed, advise nipple rolling. drying nipples with rough towel to help toughen the nipples and not to use soap or alcohol so as to prevent drying which could lead to sore nipples). e. Montgomery glands become bigger and more protruberant. f. Areolae become darker and diameter increases g. Skin surrounding areolae turns dark h. By the fourth month, a thin, watery high protein fluid, called colostrum, is formed. It is the precursor of breastmilk. Ovaries No activity whatsoever since ovulatin does not take place during pregnancy and progesterone and estrogen are being produced by the placenta. Table 2. Signs of Pregnancy

5.

STAGE

PRESUMPTIVE

PROBABLE

POSITIVE

FIRST Amenorrhea TRIMESTER Morning sickness Breast changes Fatigue Urinary frequency Enlarging of abdomen 2nd & 3rd Quickening TRIMESTER Increased skin pigMentation: Chlopasma Linea nigra Striae grvidarum

Chadwicks Ultrasound evidence Goodells Positive HCG Elevation of basal Body temperature

Enlarge abdomen Braxton Nicks Ballotament

Fetal heart tones Fetal movements fetal outline on X-ray

VII.

The Prenatal Visit The provision of prenatal care is the primary factor in the improvement of maternal mortality and mortality statistics. To ensure the success of the prenatal care program. It should be remembered that the patients understanding of the mortalities of care is basic to cooperative action. A. 1. Diagnosis of Pregnancy Urine examination human chorionic gonadobropin (HCG) in the urineis the basis for pregnancy test. It is present from the40th day through the 100th day, reaching a peak level on the 60th. HCG therefore, it most correct a weeks rites the LMP. When collecting urine for pregnancy testing
13

a. b. c. d.

No water taken after 8 PM the night before urine collection in order to concentrate urine. First morning urine, midstream, should be collected in a clean, dry jar. If more than 1 hour would lapse before being tested, refrigerate specimen because HCG is unstable under room temperature. Types of urine exams for pregnancy: Biological test Presence of HCG will produce hemorrhagic changes in the ovaries/testes of the animal when the urine of a pregnant woman is injected. e.g., Asheim-Zondek mice: Friedman, rabbit: Frank Berman rat: Hogben toad: male frog. It is already obsolete Immunodiagnostic test - antigen-antibody reaction. Widely used at present because results are obtained faster and do not involved the sacrifice of an animal e.g., Gravindex; Pregnex; Prognosticon

2.

Progesterone Withdrawal Test also a test to diagnose pregnancy. A contraceptive pill is taken by the woman three times a day for 3 days or a test pill (Gestex) is taken once. If menstruation occurs 10-15 days after, the woman is not pregnant. If pregnant there will be no menstruation because the corpus luteum produces enough hormones to neutralize the effect of withdrawn systemic progesterone. Components of a Prenatal visit History taking a. Personal data patients name, age, address, civil status (an unwed pregnancy is a risk pregnancy) and family history (with whom does she live? Are there familial diseases that could possibly affect the pregnancy?) b. Obstetrical data Gravida number of pregnancies a woman has had Para number of viable deliveries, regardless of number and outcome TPAL score (_ _ _ _) number of full term babies; premature babies; abortions; living children Past pregnancies ** Method of delivery normal spontaneous vaginal? Caesarian Section (CS)? Indication for past CS? ** Where AT home? In the hospital? ** Risk involved Prematurity? Toxemia? Present pregnancy ** Chief concern Is there nausea and vomiting? 10 Danger Signals: 1. Vaginal bleeding, no matter how slight 2. Swelling of face or fingers (General edema) 3. Severe continuous headache 4. Dimness or blurring of vision 5. Flashes of light or dots before the eyes 6. Pain in the abdomen 7. Persisting vomiting 8. Chills and fever 9. Sudden escape of fluids from the vagina 10. Absence of fetal heart sounds after they have been initially ausculcated on the 4th or 5th month. C. Medical Data Is there a history of kidney, cardiac or liver diseases; hypertension; tuberculosis; sexually transmitted diseases (STDs)? Assessment a. Physical examination a review of system is indicated, including inspection of the teeth because they are common foci of infection.
14

B. 1.

2.

b.

c.

Pelvic examination (Cardinal rule: Empty the bladder first) Internal Exam (IE) to determine Hegars, Chadwicks, and Goodells Ballotement fetus will bounce when lower uterine segment is tapped sharply (on 5th month of pregnancy) Papanicolau smear (Pap smear) cytological examination to diagnose carcinoma. Classification of findings: Class 1 Absence of typical or abnormal cells (normal) Class 2 A typical cytology but no evidence of malignancy Class 3 cytology suggestive of malignancy Class 4 cytology strongly suggestive of malignancy Class 5 conclusive for malignancy Clinical stages that reflect localization of spread of malignant changes: Stage 1 CA confined to the cervix Stage 2 CA extends beyond cervix into the vagina, but not in the pelvic wall or lower 1/3 of the vagina Stage 3 metastasis to the pelvic wall Stage 4 metastasis beyond pelvic wall into the bladder and rectum Pelvic measurements are preferably done after 6th lunar month. X-ray pelvimetry (several flat plate X-ray pictures of the pelvis are taken from different angle), however, is the most effective method of diagnosing cephalopelvic disproportion (CPD). But since X-rays are texatogenic, the procedure can only be done only 2 weeks before FDC. Leopolds maneuvers to determine presentation, position and attitude; estimate fetal size and locate fetal parts. Preparatory steps: ** Palpate with warm hands; cold hands cause abdominal muscles to contract ** Use palms, not fingertips ** Position patient on supine, with knees flexed slightly (dorsal recumbent position) so as to relax the abdominal muscles ** Use gentle but firm motions Procedure ** First maneuver: facing head part of pregnant woman, palpate for the fetal part found in the fundus to determine presentation (a hard, smooth, round, ballotable mass at the fundus means the fetus is in breech presentation) ** Second Maneuver: Palpate sides of the uterus to determine the location of the fetal back and small fetal parts ** Third maneuver: Grasp lower portion of abdomen just above the symphisis pubis to find out degree of engagement ** Fourth maneuver: Facing the feeth part of the patient, press fingers downward on both sides of the uterus above the inguinal ligaments to determine attitude (degree of flexion of fetal head) Vital signs Temperature and pulse and respiratory rate are important especially during the initial prenatal visit. But certainly more important are the weight and blood pressure as baseline data to determine any significant increases. Blood studies blood typing complete blood count, including Hgb and Hct to determine anemia serological test (VDRL and Kahn and Wasserman) to diagnose for syphilis Urine examinations
15

d.

e.

Heat and Acetic Acid Test to determine albuminuria. Any sign of albumin in the urine should be reported immediately because it is a serious sign of toxemia. Benedicts test for glycosuria, sign of possible gestational diabetes. Specimen should be taken before breakfast to avoid false positive results. Should not be more than +1 sugar. Determine of pyuria. Urinary Tract Infection has been found to be a common cause of premature delivery.

3.

Important Estimates a. Estimates of Age of Gestation (AOG): Nageles Rule calculation of expected date of confinement (EDC). Count back 3 months from the first day of the last menstrual period (LMP) then add 7 days. Substitute number for month for easy computation. McDonalds Method determines age of gestation by meeasuring from the fundus to the symphysis pubis (in cm.) then divide by 4 = AOG in months. (e.g., fundic height of 16 cm divided by 4 = 4 months AOG = 16 weeks AOG). Bartholomews Rule estimates AOG by the relative positive of the uterus in the abdominal cavity (figure 4). By the third lunar month, the fundus is palpable slightly above symphysis pubis On the 5th lunar month, the fundus is at the level of the umbilicus. On the 9th lunar month, the fundus is below the xiphoid process.

9th month

8th & 10th month 5th month 3rd month

Figure 4. Bartholomews Rule b. Heases Rule determines the length of the fetus in centimeters. During the first half of pregnancy, square the number of the month (e.g., first lunar month: 1 X 1 = 1 cm) During the second half of pregnancy, multiply the month by 5 (e.g., 6th lunar month: 6 X 5 = 30 cm) Johnsons Rule estimates the weight of the fetus in grams. Formula: Fundic height in cm. n x k K is a constant, it is always 155 n is = 12 (if fetus is engaged) = 11 (if fetus is not yet engaged)
16

c.

4.

Health Teachings a. Nutrition most important aspect women who need special attention Pregnant teenagers Extremes in weighing scale low pre-pregnant weight and obese Low income women Successive pregnancies Vegetarians although with high vitamin intake, are low in proteins and minerals amino acids that can be found only in animal sources. Nutritional assessment is based on taking a diet history first: Food preferences/eating habits Cultural/Religious influences Educational/occupational level Computation of caloric equivalents: Carbohydrates X 4 Proteins X 4 Fats X 9

Table 3. Recommended Daily Allowances

NUTRIENTS Calories (Kcal) Proteins (Gm) Vitamin A (IU) Vitamin B (IU) Vitamin E (IU) Ascorbic Acid (mg) (Vitamin C) Folic Acid (mg) Niacin (mg) Riboflavin (mg) Thiamine (mg) Vitamin B12 (ug) Vitamin B6 (mg) Calcium (mg) Phosphorus (mg) Iodine (ug) Iron (mg) Magnesium (mg)

NONPREGNANT 2000 46 55 4000 400 12 45 400 13 1.2 1.0 3.0 2.0 300 800 100 18 300

PREPREGNANT + 300 400 + 30 + 1000 +0 +3 + 15 + 400 +2 + 0.3 + 0.3 + 1.0 + 0.5 + 400 + 400 + 25 + 18 + 150

Food Sources: Protein-rich food meat, fish, eggs, milk, poultry, cheese, beans, monggo Vitamin A eggs, carrots, squash, all green leafy vegetables Vitamin D fish, liver, eggs, milk, (excess vitamin D during pregnancy can lead to fetal cardiac problems Vitamin E green leafy vegetables, fish Vitamin C tomatoes, guava, papaya, Vitamin B food rich in proteins Calcium/Phosphorus milk, cheese
17

Iron especially important during the last trimester when the pregnant woman is going to transfer her iron stores from herself to her fetus so that the baby has enough iron stores during the first three months of life when all he takes is milk (which is deficient in iron). Iron has a very low absorption rate; only 10% of the iron intake can be absorbed by the body. Thus, for optimum absorption, give Vitamin C. iron should be given after meals because it is irritating to the gastric mucosa. Sources: liver and other internal organs, camote tops, kagkong, eggyolk, ampalaya. Malnutrition during pregnancy can result in prematurity, preeclampsia, abortion, low birth weight babies, congenital defects or even stillbirths.

b.

Smoking causes vasoconstriction, leading to low birth weight babies and therefore, contraindicated during pregnancy Table 4. Quantities of Food Necessary During Pregnancy

NUTRIENTS Meat

ACTIVE NON-PREGNANT 2 servings of meat, fowl or fish/day; 3-5 eggs per week

PREGNANT 2-3 servings of meat, fowl or fish per day; 1 egg daily 1 serving daily

Vegetables: Dark green Or deep yellow Other vegetables Fruits: Citrus Other fruits Bread & Cereals Milk

1 serving (at least 3/week)

2 or more servings

2-3 servings

1 serving 1 serving 4 or more servings 1 pint (2-8 oz. glasses)

1 serving 1 serving 4 servings 1 quart (3-4 oz glasses) at least 2 glasses/day

Additional fluid

Ad libitum

c.

Drinking in moderation is not contraindicated but when excessive can cause transient respiratory depression in the newborn and fetal withdrawal syndrome; besides, alcohol supplies only empty calories. Drugs dangerous to fetus especially during the first trimester when the placental barrier is still incomplete and the different body organs are developing. Are teratogenic (can cause congenital defects) and, therefore, contraindicated unless prescribed by the doctor. Thalidomide causes amelia or phocomelia Steroids can cause cleft palate and even abortion

d.

18

Iodides (contained in may over-the-counter cough suppresants) cause enlargement of the fetal thyroid gland, leading to trancheal decompression and dyspnea at birth. Vitamin K causes hemolysis and hyperbilirubinemia. Aspirin/phenobarbital causes bleeding disorders Streptomycin/quinine causes damage to the 8th cranial nerve (nerve deafness) Tetracycline causes staining of tooth enamel and inhibits growth of long bones (not given also to children below 8 years for the same reasons)

e.

Sexual activity Sexual desires continue throughout pregnancy, but level change: During the first trimester, there is a decrease in sexual desires because the woman is more preoccupied with the changes in her body. During the second trimester, there is an improvement in sexual desires the woman has adapted to the growing fetus. During the third trimester, there is another decrease in sexual desires because the woman is afraid of hurting the fetus. Sex in moderation is permitted during pregnancy but NOT during the last 6 weeks of pregnancy it has been found out that there is increase incidence of postpartum infection in women who engaged in sex during the last 6 weeks, counsel the couple to look for more comfortable positions. Sex is contraindicated in the following situations: Spotting or bleeding Incompetent cervical os Ruptured BOW Deeply-engaged presenting pa Employment as long as the job does not entail handling toxic substances, or lifting heavy objects, or excessive physical or emotional stain, there is no contraindication to working. Advise pregnant women to walk about every few hours to her work day during long periods of standing or sitting to promote circulation. Travelling no travel restrictions, but postpone a trip during the last trimester. On long rides, 15-20 minute rest periods every 2-3 hours to walk about on empty the bladder is advisable. Exercises Chief aim: To strengthen the muscle used in labor and delivery Should be done in moderation Should be individualized: according to age, physical condition, customary amount of exercise (swimming or tennis not contraindicated unless done for the first time) in the stage of pregnancy Recommended Exercises: Squatting (figure 5) and tailorsitting (figure 5) half stretch and strengthen perineal muscles; increase circulation in the perineum; make pelvic joints more pliable. When standing from squatting position, raise buttocks first before raising the head to prevent postural hypotension. Pelvic Rock (figure 7) maintains good posture; relieves abdominal pressure and low backaches; strengthens abdominal muscles following delivery. Modified knee-chest position (figure 8) relieves pelvic pressure and cramps in the thighs or buttocks; relieves discomfort from hemorrhoids Shoulder-circling (figure 9) strengthens muscles in the chest. Walking said to be the best exercise
19

f.

g.

h.

 i.

Kagal relieves congestion and discomfort in pelvic region; tones up pelvic floor muscles

Prepared Childbirth/Childbirth Education Operates basically on the Gate Control Theory of pain: Pain is controlled in the spinal cord. The ease pain in one body part, the gate to this pain should be closed. Premises: Discomfort during labor can be minimized if the womens abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall with contractions. Major approaches to prepared childbirth-pregnant couples are taught about anatomy, pregnancy, labor and delivery, relaxation technique, breathing exercises, hygiene, diet, comfort measures. Grantly-Dick Read Method: Fear leads to tension and tension leads to pain. Lamaze psychoprophylactic method: based on the stimulus-response conditioning. To be effective, full concentration on breathing exercises during labor should be observed. (Implication: Nurse should not interrupt the couple doing breathing exercises).

j. Tetanus immunization given 0.5 ml IM (deltoid region of the upper arm) to all pregnant women any time during pregnancy. It shall be given to two doses at least 4 weeks apart, with the second dose at least 3 weeks before delivery. Booster doses shall be given during succeeding pregnancies regardless of the interval. Three booster doses will confer a lifelong immunity. k. Clinical Appointments: First 7 lunar months every month On 8th and 9th lunar months every other week = twice a month On 10th lunar month every week until labor pains set in LABOR AND DELIVERY I. The fetal Skull (figure 10) a. Importance: From an Obstetrical point of view the fetal skull is the most important part of the fetus because: 1. It is the largest part of the body 2. It is the most frequent presenting part 3. It is the least compressible of all parts b. Cranial bones the first three are not important because they lie at the base of the cranium and, therefore, are never the presenting parts. 1. Sphenoid 4. Frontal 2. Ethmoid 5. Occipital 3. Temporal 6. Parietal Membrane spaces suture lines are important because they allow the bones to move and overlap, changing the shape of the fetal head in order to fit through the birth canal, a process called Molding. 1. Sagittal suture line the membranous interspace which joins the 2 parietal bones. 2. Coronal suture line the membranous interspace which joins the frontal bone and the parietal bones
20

c.

3.

Lambdoid suture line the membranous interspace which joins the occiput and the parietal

d.

Fontanelles membrane-covered spaces at the junction of the main suture lines: 1. Anterior fontanelle the larger, diamond shaped fontanelle which closes between 12-18 months in an infant. 2. Posterior fontanelle the smaller, triangular-shapred fontanelle which closes between 2-3 months in the infant.

Figure 10. The Fetal Skull

e.

Measurements the shape of the fetal skull causes it to be wider in its anteroposterior (AP) diameter than its transverse diameter: 1. Transveres diameters of the fetal skull: a. Biparietal 9.25 cm b. Bitemporal 8 cm c. Bimastoid 7 cm 2. Anteropostrior diameters (figure 11) a. Suboccipitobregmatic from below the occiput to the anterior fontanelle 9.5 cm (the narrowest AP diameter. b. Occipitofrontal from the occiput to the mid-frontal bone = 12 cm
21

c.

Occipitomental from the occiput to the chin = 13.5 cm (the widest AP diameter)

Figure 11. Anteroposterior Diameters of the Frontal Skull

A B C

Suboccipitobregmatic Occipitofrontal Occipitomental

Which one of these diameters is presented at the birth canal depends on the degree of flexion (known as attitude) the fetal head assumes prior to delivery. In full flexion (very good attitude when the chin is flexed on the chest), the smallest suboccipitobregmatic diameter is the one presented at the birth canal. If in poor flexion, the widest occipitomental diameter will be the one presented and will give mother and baby more problems II. Theories of Labor Onset a. Uterine Stretch Theory any, hollow body organ when stretched to capacity will necessarily contract and empty. b. Oxytocin theory labor, being considered a stressful event, stimulates the hypophysis to produce oxytocin from the posterior pituitary gland. Oxytoxin causes contraction of the smooth muscles of the body, e.g., uterine muscles. c. Progesterone Deprivation theory progesterone, being the hormone designed to promote pregnancy, is believed to inhibit uterine motility. Thus, if its amount decreases, labor pains can occur. d. Prostaglandin theory initiation of labor is said to result from the release of arachidonic acid produced by steroid action on lipid precursors. Arachidonic acid is said to increase prostaglandin synthesis which in turn, causes uterine contractions. e. Theory of Aging Placenta because of the decreased blood supply, the uterus contracts. Preliminary/prodromal Signs of Labor a. Lightening the settling of the fetal head into the pelvic brim. In primis, it occurs 2 weeks before FDC; in multis, on or before labor onset. Results of lightening: 1. Increase in urinary frequency 2. Relief of abdominal tightness in diaphragmatic pressures.
22

III.

3. 4.

Shooting pains down the legs because of pressure on the sciatic nerve. Increase in the amount of vaginal discharges. Lightening should not be confused with engagement. Engagement occurs when the presenting part has descended into the pelvic inlet.

b.

Increased activity level due to increase epinephrine secreted to prepare the body for the coming work ahead. Advise the pregnant woman not to use this increased energy for doing household chores. Loss of weight of about 2.9 pounds 1 to 2 days before labor onset, probably due to decrease in progesterone production leading to decrease in fluid retention. Braxton Hicks contractions painless, irregular practice contractions. Ripening of the cervix from Goodells sign, the cervix becomes butter soft. Rupture of the membranes it is IMPORTANT to remember that once membranes (BOW) have ruptured: 1. Labor is inevitable. It will occur within 24 hours. 2. The integrity of the uterus has been destroyed. Infection, therefore , can easily set in. that is why once membranes have ruptured, aseptic techniques should be observed in all procedures, doctors do less obstetric manipulations (e.g., IE) and enema is no longer ordered. 3. Umbilical cord compression and/or cord prolapse can occur (especially in breech presentation). Nursing action depends on the specific situation. a. A woman in labor seeking admission to the hospital and saying that her BOW has ruptured should be put to bed immediately and the fetal heart tones taken consequently. b. If a woman in the Labor Room says that her membranes have ruptured, the initial nursing action is to take the fetal heart tones. c. If a woman in labor says that she feels a loop of the cord coming out of the vagina (cord prolapsed), the first nursing action is to put her on Trendelenberg position (lower the head of the bed) in order to reduce pressure in the cord (REMEMBER: Only 5 minutes of cord compression can already lead to irreversible brain damage or even death). In addition, apply a warm saline saturated OS on the prolapsed cord to prevent drying of the cord. Show Due to pressure of the descending presenting part of the fetus which causes rupture of minute capillaries in the mucous membrane of the cervix. Blood mixes with mucus when Operculum is released. Show, therefore, is only a pinkish vaginal discharge.

c.

d. e. f.

g.

IV.

Signs of True Labor a. Uterine Contractions the unrest sign that labor has begun is the initiation of effective, productive uterine contractions. 1. Pain in uterine contractions results from: a. Contraction of uterine muscle when in an ischemic state. b. Pressure on nerve ganglia in the cervix and lower uterine segment. c. Stretching of ligaments adjacent to the uterus and in the pelvic joints. d. Stretching and displacement of the tissues of the vulva and perineum.

2.

Phases of uterine contractions (figure 12) a. Increment 1st phase during which the intensity of contraction increase, also known as cresendo.
23

b. c.

Acme the height of the uterine contraction, also known as apex Decrement last phase during which intensity of contraction decreases; also known as decresend

Figure 12. Phases of Uterine Contractions

Table 5. Differences between False and True Labor Pains FALSE LABOR PAIN 1. Remain irregular TRUE LABOR PAIN 1. May be slightly irregular at first but become regular and predictable in a matter of hours. 2. First felt in the lower back and sweep around to the abdomen in a girdlelike fashion. 3. Increased in duration, frequency and Intensity. 4. Continue no matter what the womans level of activity is. 5. Accompanied by cervical effacement and dilatation (most important difference).

2. Generally confined to the abdomen

3. No increase in duration, frequency and intensity. 4. Often disappears if the woman ambulates 5. Absent cervical changes

b.

Effacement Shortening and thinning of the cervical canal as distinct from the uterus exists. It is express in percentage. Dilatation Enlargement of the external cervical Os to 10 cm primarily as a result of uterine contractions and, secondarily, as a result of pressure ofteh presenting part and the BOW. Uterine Changes The uterus is gradually differentiated into a distinct portions: (figure 13): 1. Upper uterine segment becomes thick and active to spell out fetus 2. Lower uterine segment becomes thin-walled, supple and passive so that fetus can be pushed out easily.

c.

d.

Physical retraction ring is formed at the boundary of the upper and lower uterine segments. In difficult labor when fetus is larger than the birth canal, the round ligaments of the uterus become tense during dilatation and expulsion, causing an abdominal indentation called Bandls pathological retraction ring, a danger sign of labor signifying impending rupture of the uterus if the obstruction is not relieved.

24

V.

Length of Normal Labor Primis Multis

First Stage 12 hours 1 hour, 20 minutes Second stage 80 minutes 30 minutes Third stage 10 minutes 10 minutes _________________________________________________ TOTAL 14 hours 8 hours

Figure 13. Effacement and Dilatation of Cervix

Upper Uterine Segment Lower Uterine Segment Cervix

VI. A.

Stages of Labor First Stage (Stage of Dilatation) begins with true labor pains and ends with complete dilatation of the cervix. 1. Power/Forces: Involuntary uterine contractions 2. Phases: a. Latent Early time in labor Cervical dilatation is minimal because effacement is occuring. Cervix dilates 3-4 cm only Contractions are of short duration and occur regularly 5-10 minutes apart (during which time the pregnant woman may seek admission to the hospital). Mother is excited, with some degree of apprehension but still with ability to communicate. Takes u 8 of the 12-hour first stage b. Active/accelerated cervical dilatation reaches 4-8 cm rapid increase in duration, frequency and intensity of contractions. Mother fears losing control of herself Nursing Care a. Hospital Admission provide privacy and reassurance from the very start. Personal Data name, age, address, civil status Obstetrical Data determine EDC; obstetrical score, amount and character of show; and whether or not membranes have ruptured b. General and Physical Examination, internal exam and Leopolds maneuvers are done to determine: Effacement and dilatation Station relationship of the fetal presenting part of the level of the ischial spines (figure 14).
25

3.

Station 0 at the level of the ischial spines; synonymous to engagement Station -1 = presenting part above the level of the ischial spines Station +1 = presenting part below the level of the ischial spines Station +3 or +4 = synonymous to crowning (=encircling of the largest diameter of the fetal head by the vulval ring) Presentation relationship of the long axis of the fetus to the long axis of the mother; also known as lie Presenting part the fetal part which enters the pelvis first and covers the internal cervical os.

Figure 14. Stations

I. A.

VERTICAL Cephalic head is the presenting part 1. Vertex head sharply flexed, making the parietal bone the presenting part 2. Face 3. Brow if in poor flexion 4. chin Breech buttocks are the presenting parts 1. Complete thighs flexed on the abdomen and legs are on the thighs 2. Frank thighs are flexed and legs are extended, resting on the antrior surface of the body. 3. Footling a. Single one leg unflexed and extended, one foot presenting b. Double legs unflexed and extended, feet are presenting HORIZONTAL Transverse lie = shoulder presentation Table 6. Type of Presentation In vertex and breach presentations, fetal heart sounds are based heard at the area of the Dacel Hack. In face presentations, at the area of the fetal chest. In vertex presentations, FHS are usually located in either the left or right lower quadrant (LLQ or RLQ) in breech presentations, at or above the level of the umbilicus (RUQ or LUQ) Hazards of breech delivery: ** Cord compression ** Abruptio placenta ** Horizontal lie is very rare (1%) and maybe due to the relaxed abdominal wall because of multiparity, pelvic contractions of placenta previa Position relationship of the fetal presenting part to a specific quadrant of the mothers pelvis. The pelvis is divided into 4 quadrants:
26

B.

II.

** ** ** ** **

LST

Right anterior Right posterior Left anterior Left posterior Posterior positions results in more backaches because of pressure of fetal presenting part on the maternal sacrum. Points of direction in the fetus: ** Occiput in vertex presentation ** sacrum in breech presentation ** Scapula (acromio) in horizontal presentation Possible fetal positions: ** Vertex LOA left occipitoanterior (most common and favorable position at birth) LOP left occipitoposterior LOT left occipitotransverse ROA right occipitoanterior ROP right occipitoposterior ROT right occipitotransverse ** Breech LSA left sacroanterior LSP left sacroposterior left sacrotransverse RSA right sacroanterior RSP right sacroposterior ** Face LMA left mentoanterior LMP left mentoposterior LMT left mentotransverse RMO right mentoanterior RMP right mentoposterior RMT right mentotransverse ** Shoulder LADA LADP RADA RADP -

left acromiodorsoanterior left acromiodorsoposterior right acromiodorsoanterior right acromiodorsoposterior

c.

Monitoring and evaluating of important aspects Uterine contractions fingers should be spread lightly over the fundus (figure 15) Duration from the beginning of one contraction to the end of the same contraction (A to B) ** Duration during early labor = 20-30 seconds. ** Duration late in labor = 60-70 seconds (SHOULD NEVER BE LONGER) Interval from the end of one contraction to the beginning of the next contraction (B to C) ** Interval early in labor = 40-45 minutes ** Interval late in labor = 2-3 minutes Frequency from the beginning of one contraction to the beginning of the next contraction (A to C). time 3-4 contractions to have a good picture of the frequency of the contractions. Intensity strength of contractions. May be mild, moderate, or strong. Intensity is measured by the consistency of the fundus at the acme of the
27

contraction. When estimating intensity, check fundus at the end of contractions to determine whether it relaxes.

Figure 15. Aspects of Contraction

Blood pressure should not be taken during a contraction as it tends to increase. Because no blood supply goes to the placenta during a contraction, all of the blood is in the periphery that is why there is increased BP during uterine contractions. BP reading should be taken at least every half hour during active labor. When a woman in labor complains of headache, the first nursing action is to take BP, if it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of toxemia) Fetal Heart Rate should not be mistaken for uterine souffle (synchronizes with maternal pulse rate). Normally 120-160 per minute Should not be taken also during uterine contraction because it tend to decrease. Compression of the fetal head when the uterus contracts stimulates the vagal reflex which, in turn, results to bradicardia. Should be taken every hour during the latest phase of labor; every half hour during the active phase and every 15 minutes during the transition phase. For any abnormality inFHR, the initial nursing action is to change the mothers position. Signs of fetal distress: ** Bradycardia (FHR less than 100/minute) or tachycardia (FHR more than 180/minute) ** Meconium-stained amniotic fluid in non-breech presentation ** Fetal thrashing Hyperactivity of the fetus as it struggles for more oxygen. Emotional support is provided for the woman in labor by constantly informed of the progress of labor. keeping her

d.

e.

Health Teachings: Bath is advisable if contractions are tolerable or not too close to one another. Will make the mother feel more comfortable. Ambulation during the latent phase of labor helps shorten stage of labor. But definitely not allowed anymore if membranes have ruptured. Solid or liquid foods are to be avoided because: Digestion is delayed during labor. A full stomach interferes with proper bearing down. May vomit and cause aspiration.
28

Enema NOT a routine procedure Purposes ** A full bowel hinders the progress of labor-effectiveness if enema in labor is shown by evaluating change in uterine tone and amount of show. ** Expulsion of feces during second stage of labor predisposes mother and baby to infection. ** Full bowel predisposes to postpartum discomfort. Procedure of enema administration : ** Enema solution may either be soap suds or fleet enema. ** Optimal temperature of the enema solution = 105 deg. F to 115 deg. F (40.15 deg. C 46.1 deg. C) ** Patient on side-lying position ** When there is resistance while inserting the rectal catheter, withdraw the tubes slightly while letting small amount of solution enter. ** Clamp rectal tube during a contraction ** Important nursing action: Check FHR after enema administration to determine fetal distress. Encourage the mother to void every 2-3 hours by offering the bedpan because: A full bladder retards fetal descent Urinary stasis can lead to urinary tract infection A full bladder can be traumatized during delivery. Perineal prep done aseptically, use No. 7 method, always front to back. Perineal shave maybe done to provide a clean area for delivery. Muscles at the symphysis pubis should be kept taut and razor moved along the direction of hair growth. Encounter Sims position because: It favors anterior rotation of the fetal head It promotes relaxation between contractions It prevents continual pressure of the gravid uterus on the inferior vena cava (the blood vessel which brings unoxygenated blood back to the heart); pressure results in SUPINE HYPOTENSIVE SYNDROME. Hypotension is due to the reduced venous return resulting in decreased cardiac output and therefore, a fall in anterial BP. Woman in labor should not be allowed to push or bear down unnecessarily during contractions of the first stage because: It leads to unnecessary exhaustion. Repeated strong pounding of the fetus against the pelvic floor will lead to cervical edema, thus , interfering with dilatation. Abdominal breathing is advised for contraction during the first stage in order to reduce tension and prevent hyperventilation. Administer analgesics as ordered. The dosage is based on the patients weight, status of labor and size and stage of gestation. Narcotics are the most commonly used specifically DEMEROL. Pharmacologic effects: ** Depresses the sensory portion of the cerebral cortex. It is not only as potent analgesic, it is also a sedative and an antispasmodic. It is not given early in labor because it can retard labor progress (is an antispasmodic), but cannot also be given if delivery is only in cervical dilatation is 6-8 cm. Given 25-100 mg, depending on the body weight.
29

f.

 g.

Takes effect in 20 minutes patient experience a sense of well-being and euphoria. Narcotics antagonist (e.g., Narcan or Nalline) are given to counteract the toxic effect of Demerol.

h.

Assist in administration of regional anesthesia prepared over any other form or anesthesia because it does not enter material circulation and thus does not effect the fetus. Patient is completely awake and aware of what is happening. Does not depress uterine, does optimal uterine contraction is achieved. Xyclocaine is anesthesia of choice Patient on NPC with IV to prevent dehydration, exhaustion and aspiration and because glucose aids uterine muscles in proper functioning. Types of anesthesia: Paracervical = transvaginal injection into either side of the cervix. Patient on lithotomy position. Coupled with a local anesthsia, results in painless childbirth (uterine contractions are not felt by mother). Pudental = through the sacrospinous ligament into the posterior perception of pain during second stage and make mother comfortable. Patient on lithotomy. Side effect: an etchymotic (purplish discoloration of skin due to blood in the subcutaneous tissues) area or hematoma in the right of the perineum maybe aftermath. No special treatment is needed: ice bag applied to the area on the first day may reduce the swelling. Low spinal ** Epidural = injection or local anesthetic at the lumbar level outside the dura meter. ** Saddle block = injection into the fifth lumbar space, causing anesthesia into the parts of the body that come in contact with a saddle (perineum, upper thighs and lower pelvis). Blocks nerves that transmit pain of first stage of labor. In sitting of side-lying position, with back flexed. Forceps are generally needed in delivery of patient under anesthesia because of loss of coordination in second stage pushing. Post spinal headaches maybe due to leakage of anesthetic into the CFH or injection of air at time of needle insertion Management: Flat on bed for 12 hours and increase fluid intake Common side-effects: Hypotension because Xylocaine is a vasodilator. Management: Turn to side; prompt elevation of legs; administration of vasopressor and oxygen, as ordered. Fetal bradycardia Decreased maternal respiration. A sure sign that the baby is about to be born is the bulging of the perineum. In general, primigravidas are transported form the LR to the DR when the cervix is fully dilated or when there is bulging of the perineum: multiparas are transported at 7-8 cm. Cervical dilatation.

B.

Transition Period when the mood of the woman suddenly changes and the nature of the constructions intensify 1. Characteristics: a. If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is pushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOW with a sterile pointed instrument, e.g., Kelly or Allis forceps or amniohook to allow amniotic fluid to drain), is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetal position
30

b. c.

d. e. 2.

changes. Amniotomy, however, can not be done if station is still minus, as this can lead to cord compression. Show becomes more prominent. There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor. Profuse perspiration and distension of neck veins are seen. Nausea and vomiting is a reflex reaction due to decreased gastric motility and absorption. In primis, baby is delivered within 20 constraction (40 min): in multis, in 10 contractions (20 min).

Nursing actions are primarily comfort measures: a. Sacral pressure (applying pressure with the heel of the hand on the sacrum) relieves discomfort form contractions. b. Proper bearing down techniques: push with contractions. c. Controlled chest (inter-costal) breathing during contractions. d. Emotional support

C.

Second Stage (Stage of Expulsion) begins with complete dilatation of the cervix and ends with delivery of the baby. 1. Powers/forces: Involuntary uterine contractions and contractions to the diaphragmatic and abdominal muscles. 2. Mechanisms of Labor/Fetal Position Changes (D FIRE ERE) a. Descent (may be preceded by engagement) b. Flexion as descent occurs, pressure from the pelvic floor causes the chin to bend forward into the chest. c. Internal rotation from AP to Transverse, the AP to AP. d. Extension as head come out, the back of the neck stops beneath the pubic arch. The head extends and the forehead, nose, mouth and chin appear. e. External rotation (also called restitution-anterior shoulder rotates externally to the AP position. f. Expulsion delivery of the rest of the body. 3. Nursing Care a. When positioning legs on lithotomy, put them up at the same time to prevent injury to the uterine ligaments. b. As soon as the fetal head crowns, instruct mother not to push, but to pant instead (rapid and shallow breathing). If panting is deep and rapid, called hyperventilation the patient will experience light headedness and tingling sensation of the fingers leading to carpopedal spasma, because of respiratory alkalosis. Management: let the patient breath into a brown paper bag to recover lost carbon dioxide; cupped hand will serve the same purpose. c. Assist in episiotomy surgical made in the perineum primarily to prevent lacerations Other purposes of episiotomy: Prevent prolonged and severe stretching of muscles supporting bladder or rectum. Reduce duration of second stage when there is hypertension or fetal distress. Enlarge outlet, as in breech presentation or forceps delivery. Types of episiotomy:
31

d.

e.

f.

g. h. i.

j. D.

Median from middle portion of the lower vaginal border directed towards the anus. Mediolatera begun in the midline but directed laterally away from the anus. Natural anesthesia is used in episiotomy, i.e., no anesthetic is injected because pressure of fetal presenting part against the perineum is so intense that nerve endings for pain are momentarily deadened. Apply the Modified Ritgens Maneuver: Cover the anus with sterile towel and exert upward and forward pressure on the fetal chin, while exerting gentle pressure with two fingers on the head to control emerging head. This will not only support the perineum, thus preventing lacerations, but will also favor flexion so that the smallest suboccipitobregmatic diameter of the fetal head is presented. Ease the head out and immediately wipe the nose and mouth of secretions to establish a patent airway (REMEMBER: The first priciple in the care of the newborn is established and maintain a patent airway). (The head should be delivered in between contractions). Insert two fingers into the vagina so as to feel for the patient of a cord looped around the neck nuchal cord. If so, but loose, slip it down the shoulders or up over the head; but if tight, clamp cord twice and inch apart, and then cut in between. As the head rotates, deliver the anterior shoulder by exerting a gentle downward push and the n slowly give and upward lift to deliver the posterior shoulder. While supporting the head and the neck, deliver the rest of the body. Take note of the exact time of delivery of the baby. Immediately after delivery, newborn should be held below the level of the mothers vulva for a few minutes to encourage flow of blood from the placenta to the baby. The infant as held with his head in the dependent position (head lower than the rest of the body) to allow for drainage of secretions. REMEMBER: Never stimulate a baby to cry unless to have drained him out of his secretions first. Wrap the baby in a sterile diaper to keep him warm. REMEMBER: Chilling increases the bodys need for oxygen. Put the baby on the mothers abdomen. The weight of the baby will help contract the uterus. Cutting of the cord is postponed until the pulsation have stopped because it is believed that 50-100 ml of blood is flowing from the placenta to the baby at this time. After cord pulsation have stopped, clamp it twice, an inch apart, and then cut in between. Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the circulating nurse.

Third Stage (Placental Stage) Begins with the delivery of the baby and ends with the delivery of the placenta. 1. Signs of placental separaton: a. Uterus becoming round and firm again, rising high to the level of umbilicus (Calkins sign) the earliest sign of placental separation. b. Sudden gush of blood from the vagina. c. Lengthening of the cord from the vagina. 2. Types of placental delivery: a. Shultz If placenta separates first at its center and last as its edges, it tends to fold on itself like an umbrella and presents the fetal surface which is shiny, 80% of the placentas separate in this manner (shinny for Shultz).

32

b.

Duncan If placenta separates first at its edges, it slides along the uterine surface and presents with the maternal surface which is raw, red beefy irregular and dirty. Only about 20% of placenta separate this way. (Dirty for Duncan).

3.

Nursing Care a. Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push is this can cause uterine inversion. Just watch for the signs of placental separation. b. Tract the cord slowly, winding it around the clamp until placenta spontaneously comes out, rotating it slowly so that no membranes are left inside the uterus, a method called Brandt-Andrews Maneuver. c. Take not of the time of placental delivery; it should be delivered within 20 minutes after the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause severe bleeding in the mother. d. Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death. e. Inject oxytocics (Methergin = 0.2 mg/ml or Syntocinon = 10 u/ml) IM to maintain uterine contractions, thus prevent hemorrhage.NOTE: oxytocics are not given before placental delivery because placental entrapment can occur. f. Inspect the perineum for lacerations. Any time the uterus is firm following placental delivery, yet bright red vaginal bleeding is gushing forth from tthevaginal opening suspect lacerations. Categories of lacerations (tends to heal more slowly because of ragged edges): First degree involves the vaginal mucous membranes and skin Second degree involves not only the vaginal mucous membranes and skin, but also the muscles. Third degree involves not only the muscles, vaginal mucous membranes and skin, but also the external sphincter of the rectum Fourth dgree involves not only the external sphincter of the rectum, the muscles, vaginal mucous membrane and skin, but also the mucous membrane of the rectum. Assist the doctor in doing episiorrhaphy (repair of episiotomy or lacerations). In vaginal episiorrhapy, packing is done to maintain pressure on the suture line, thus prevent further bleeding. NOTE: vaginal packs have to be removed after 2448 hours. g. Make mother comfortable by perineal care and apply clean sanitary napkin shugly to prevent its moving forward from the anus to the vagina. Soiled napkins should be removed from front to back. h. Position the newly delivered mother flat on bed without pillows to prevent dizziness due to decrease in intra-abdominal pressure. i. The newly delivered mother may suddenly complain of chills due to the rapid decrease of pressure, fatigue or cold temperature in the delivery room. Management: provide additional blankets to keep her warm. j. May give initial nourishment, e.g., milk, coffee or tea k. Allow patient to sleep in order to regain lost energy.

E.

Fourth Stage First 1-2 hours after delivery which is said to be the most critical stage for the mother because of unstable vital signs. 1. Assessment: a. Fundus should be checked every 15 minutes for 1 hour the nevery 30 minutes for the next 4 hours. Fundus should be firm, in the midline and during the first 12 hours postrpartum, is a little above the umbilicus. First nursing action for a noncontracted uterus: massage.
33

b. c. d. e.

Lochia should be moderate in amount. Immediately after delivery, a perineal pad can be completely saturated after 30 minutes. Bladder a full bladder is evidenced by a fundus which is to the right of the midline, darkered bleeding with some clots. Perineum is normally tender,discolored and edematous. It should be clean, with intact sutures. Blood pressure and pulse rate maybe slightly increased from excitement and effort of delivery, but normalize with 1 hour.

4.

Lactation Suppressing agents estrogen-androgen preparations given within the first hours postpartum to prevent breast milk production if mothers who will not (or cannot) breast feed. E.g, diethylstilbestrol, TACE or deladumone, these drugs tend to increase uterine bleeding and retard menstrual return. Rooming-in Concept mother and baby are together while in the hospital. The concept of a family, therefore, is felt at the very beginning because parents have the baby with them, thus providing opportunities for developing a positive relationship between parents and newborn. Eye to eye contact is immediately established, releasing maternal care taking responses.

3.

VII.

Dystocia Broad term for abnormal or difficult labor and delivery. A. Uterine Inertia Sluggishness of contractions 1. Causes: a. Inappropriate use of analgesics b. Pelvic bone contraction c. Poor fetal position d. Overdistention due to multiparity, multiple pregnancy, polyhydramnios or excessively large fetus. 2. a. Types: Primary (hypertonic) uterine dysfunction relaxations are inadequate and mild, thus are ineffective. Since uterine muscles are in the state of greater than normal tension, latent phase of the first stage of labor ids prolonged. Treatment: sedate the patient. Secondary (hypotonic) uterine disfunction contractions have been good but gradually become infrequent and of poor quality and dilatation stops. Treatment: stimulation of labor either by oxytocin administration or amniotomy.

b.

B.

Precipitate Delivery Labor and delivery that is completed in less than 3 hours after the ondset or true labor pains. Probably due to multiparity or following oxytocin administration of amniotomy. Dangers imposed by the precipitate delivery: extensive lacerations; abruptio placenta; or hemorrhage due to sudden release of pressure, leading to shock. Prolonged Labor In primis; labor more than 18 hours and in multis, more than 12 hours. DANGERS: Maternal exhaustion, uterine atony or caput succadereum. Uterine Rupture Occurs when the uterus undergoes more strain that it is capable of sustaining. 1. Causes: a. Scar from a previous classic Caesarean Section (C/S) b. Unwise use of oxytocins c. Over distention d. Faulty presentation or prolonged labor 2. Signs and symptoms: a. Sudden, severe pain
34

C.

D.

b. c. 3. E.

Hemorrhage and clinical signs of shock (restlessness, pallor, decreasing BP, increasing respiratory and pulse rate) Change in abdominal contour, with two swellings on the abdomen, the retracted uterus and the extrauterine fetus. Management: Hysterectomy

F.

Uterine Inversion Fundus is forced through the cervix so that the uterus is turned inside out. 1. Causes: a. Insertion of placenta at the fundus, so that as fetus is rapidly delivered, especially if unsupported, the fundus is pulled down. b. Strong fundal push when mother fails to bear down propwerly. c. Attempts to deliver the placenta before signs of placental separation appear. 2. Management: Hysterectomy Amniotic Fluid Embolism Occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after partial premature separation of the placenta. Solid particles in the amniotic fluid enter the maternal circulation and reach the lungs as emboli. 1. Signs and symptoms are dramatic. a. Woman in labor suddenly sits up and grasp her chest because of inability to breath and sharp pain. b. Turns pale and then the typical bluish gray color associated with pulmonary embolism c. Death may occur in few minutes. 2. Management: a. Emergency measures to maintain life: IV, oxygen, CPR b. Provide intensive care in the ICU c. Keep family informed and provide emotional support Trial Labor If a woman has borderline (just adequate) pelvic measurements but fetal position and presentation are good. Maybe continued for as long as there is progressive fetal descent of the presenting part and cervical dilatation. Management: a. Monitor FHRs and uterine contractions. b. Keep bladder empty to allow all available space to be used by the fetus c. Emotional support Premature Labor and Delivery If uterine contractions occur before the 38th week of gestation 1. If there is no bleeding and cervical dilatation and fetal heart sound is good, premature uterine contraction can be stop by drugs: a. Ethyl alcohol (Ethynol) IV Blocks the release of oxytocin. Side effects: Nausea and vomiting, mental confusion, etc. (same side effects when alcohol is taken orally in excessive amounts) b. Vasodilan TV A vasodilator. Side effects: hypotension and tachycardia. c. Ritodrine a muscle relaxant given orally d. Bricanyl a known brochodilator 2. If premature uterine contractions are accompanied by progressive fetal descent and cervical dilatation, premature delivery is inevitable. a. Not necessarily shorter than full term labor b. Pain medications are kept to a minimum because analgesics are known to cause respiratory depression. As it is, premature babies already have enough difficulty breathing on their own; giving analgesics, therefore, would add up to the problem. Implication: give emotional support to the mother such that she focuses her attention not on her own needs, but those of her baby.
35

G.

H.

c. d. e.

f. g.

Steroids (glucocorticoids) is given to the mother to help in maturation of fetal lungs by hastening production of surfactants. Caudal, spinal or infiltration anesthesia is preferred becauseit does not compromise fetal respiration. Episiotomy may not necessary be smaller than in full term deliveries: may even be larger so that the preemie can be delivered the shortest possible time, since excessive pressure on the fragile preemies head can cause subarachnoid hemorrhage that could be fatal. Forceps may be applied gently. Cord is cut immediately, rather than waiting for pulsation to stop because preemies have difficult time excreting large amounts of bilirubin that will be formed from the extra amount of blood.

PUERPERIUM I. Definition: A. Puerperium/postpartum refers to the six-week period after delivery of the baby. B. II. Involution The return of the reproductive organs to their prepregnant state.

Principles of Postpartum Care A. Promote healing and return to normal (involution) of the different parts of the body. 1. Vascular changes a. The 30% - 50% increase in total cardiac volume during pregnancy will be reabsorbed 5 10 minutes after placental delivery. Implication: The first 5 10 minutes after placental delivery is crucial to grvidocardiacs because the weak heart may not be able to handle such workload. b. White Blood Cells (WBC) count increases to 20,000-30,000/mm3. Implications: WBC count, therefore, cannot be used as an indicator of postpartum infection. c. There is extensive activation of the clotting factors, which encourages thromboembolization. This is the reason why: Ambulation is done early after 4-8 hours in normal vaginal delivery. When ambulating the newly delivered patient for the first time, the nurse should hold to the patients arm. Exercises are recommended: Kegal and abdominal breathing on postpartum day 1 (PPD 1) Chin-to-chest on second day to tighten and firm up abdominal muscles Knee-to-abdomen when perineum has healed, to strengthen abdominal and gluteal muscles. Massage is contraindicated. d. All blood values are back to prenatal levels by the third or fourth week postpartums.
36

2. a.

b. c.

d. >

Genital changes Uterine involution is assessed by measuring the fundus by fingerbreadths (1 cm). On PPD 1 fundus is one fingerbreadth below the umbilicus; On PPD 2, 2 fingerbreadths below the umbilicus and on so forth until on the tenth day postpartum, it can no longer be palpated because it is already behind the symphysis pubis. Subinvolured uterus a big uterus and vaginal bleeding with clots. Since blood clots are good media for bacteria, it is, therefore, a sign of perperal sepsis. To encourage return of the uterus to its usual anteflexed position, prone and knee-chest position are advised. Afterpains/after birth pains strong uterine contractions felt more particularly by multis, those who delivered large babies or twins and those who breastfeed. Management: NEVER apply heat on abdomen Give analgesics as ordered Explain that it is normal and last for more than 3 days. Lochia Uterine discharges consisting of blood, decidua, WBC, mucus and some bacteria Patterns: Rubra first 3 days postpartum; red and moderate in amount Serosa next 4-9 days pink or brownish and decreased in amount Alba from 10th day up to 3-6 weeks colorless and minimal in amount Characteristics: Pattern should not reverse It should approximate menstrual flow (however, it increases with activity and decreases with breastfeeding) It should not have any offensive odor. It has the same fleshy odor as mestrual blood. Otherwise, it means either poor hygiene or infection. It should not contain large clots It should never be absent, regardless of method of delivery. Lochia has the same pattern and amount, whether CS or Normal Vaginal Delivery. Pain in perineal region may be relieved by: Sims position minimizes strains on the suture line. Perineal heat lamp or warm Sitz baths twice a day vasodilation increases blood supply and, therefore promote healing. Application of topical analgesics or administration of mild oral analgesics as ordered. Sexual activity maybe resumed by the third or fourth week postpartum if bleeding has stopped and episiorrhaphy has healed. Decreased physiologic reactions to sexual stimulation are expected for the first 3 months postpartum because of normal changes and emotional factors. Menstruation if not breastfeeding, return of menstrual flow is expected within 8 weeks after delivery. If beastfeeding, menstrual return is expected 3-4 months; in some women no menstruation occurs during the entire lactation period. (IMPORTANT: Amenorrhea during lactation is no guarantee that the woman will not become pregnant. She may be ovulating and the absence of menstruation may be her bodys way of conserving fluids for lactation. Implication: She should be protected against a subsequent pregnancy by observing a method of contraception, but NOT the pills). Postpartum check-up Should be done after the 6th week postpartum to assess involution. Urinary changes:
37

e. f.

g.

h. 3.

a. b.

4. a. b. c. d.

There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid accumulation during pregnancy. Some newly delivered mothers may complain of frequent urination in small amounts; explain that it is due to urinary retention with overflow. Others, on the other hand, may have difficulty voiding because of decreased abdominal pressure or trauma to the trigons of the bladder. Voiding may be initiated by pouring warm and cold water alternately over the vulva, encouraging patient to go to the comfort room and let her listen to the sound of running water. If these measures fail, catheterization done gently and aseptically, is the last resort on doctors order. (if there is resistance to the catheter when it reaches the internal sphincter, ask patient rotating the catheter before moving it inward again). Gastrointestinal changes delayed bowel evacuation postpartially may be due to: decreased muscle tone lack of food + enema during labor dehydration fear or pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids. Vital signs Temperature may increase because of the dehydrating effects of labor. Implication: Any increase in body temperature during the first 24 hours postpartum is not necessarily a sign of postpartum infection. Bradycardia (heart rate of 50-70 beats/min) is common for 6-8 days postpartum. There is no change in respiratory rate Weight There is an immediate weight loss of 10-12 pounds representing the weights of the fetus, placenta, amniotic fluid and blood. Further weight loss may occur during the next days due to diaphoresis.

5. a.

b. c. 6.

B.

Provide emotional support the psychological phases during the postpartum period are: 1. Taking-in phase First 1-2 days postpartum when mother is passive and relies on others to care for her and her newborn. She keeps on verbalizing her feelings regarding the recent delivery for her to be able to integrate the experience into herself. 2. Taking-hold phase Begins to initiate actions and make decisions. Postpartum Blues (an overwhelming feeling or sadness that cannot be counted for) may be observed. Could be due to hormonal changes, fatigue or feelings of inadequacy in taking care of a new baby. Management: Explain that it is normal and that crying is therapeutic, in fact.. Prevent postpartum complications 1. Hemorrhage blood loss of more than 500 cc (normal blood loss during labor and delivery is 250-350 cc); leading cause of maternal mortality associated with childbearing. Table 7. Classification of postpartum hemorrhage Early postpartum hemorrhage occur during the first 24 hours postpartum A. Uterine Atony uterus is not well contracted, relaxed or boggy; most frequent cause: 1. Predisposing factors a. Overdistention of the uterus e.g., multiple pregnancy, multiparity, excessive large baby, polyhydramnios
38

C.

I.

B. C. II.

b. Cesarean Section c. Placental accidents (Previa or Abruptio) 2. Management: a. Massage first nursing action b. Ice compress c. Oxytocin administration d. Emptying the bladder e. Bimanual compression to explore retained placental fragments Lacerations Hypofiiorinoginemia a clotting defect

Late postpartum hemorrhage A. Retained placental fragment management: dilatation and curettage (D & C) B. Hematoma due to injury to blood vessels during delivery 1. Incidence commonly seen in precipitate delivery and those with perineal varicosities. 2. Treatment: a. Ice compress during the first 24 hours b. Oral analgesics, as ordered c. Site is incised and bleeding vessel is ligated

2. a.

b. c. d.

Infection Sources: Endogenous (primary) sources bacteria in the normal flora because virulent when tissues are traumatized and general resistance is lowered. Exogenous sources pathogens introduced from external sources. Organism most frequently responsible for postpartum infections: Anaerobic streptococci. Common exogenous sources: ** Hospital personnel ** Excessive obstetric manipulation ** Breaks in aseptic techniques faulty hanwashing, unsterile equipments and supplies ** Coitus in later pregnancy ** Premature rupture of membranes General symptoms: malaise, anorexia, fever, chills and headache General management: complete bed rest (CBR), proper nutrition, increase fluid intake, analgesic, antipyretics, and antibiotics, as ordered. Types of infection: Specific symptoms Pain, heat and feeling of pressure in the perineum Inflammation of the suture line, with 1 o2 stitches sloughed off With or without elevated temperature Specific Management: Doctor removed sutures to drain area and re-sutures. Hot Sitz Bath or warm compress. Endometritis Inflammation/infection of the lining of the uterus. Specific symptoms: ** Abdominal tenderness ** Uterus not contracted and painful to touch
39

** Dark brown, foul smelling lochia Specific Management: Oxytocin Fowlers position to drain the lochia and prevent pooling of infected discharge Thromboplebitis infection of the lining of the blood vessel with formation of clots; usually an extension of endometritis. Specific symptoms: ** Pain, stiffness and redness in the affected part of the leg ** Leg begins to swell below the lesion because venous circulation has been blocked. ** Skin is stretched to a point of shiny whiteness called milk leg phlegmasia alba dolens. ** Positive Homans Sign pain in the calf when the foot is dorsiflexed Specific Management: ** Bed rest with affected leg elevated ** Anticoagulants, e.g., Decumarol or Heparin to prevent further clot formation or extension of a thrombus *** Side effects: Hematuria and increased lochia *** Considerations: a. Discontinue breast feeding b. Monitor prothrombin time c. Always have promtamine sulfate or vitamin K at bedside to counteract toxicity. ** Analgesics are given but NEVER Aspirin because it inhibits prothrombin formation; since patient is already receiving an anticoagulant, bleeding may occur.

D.

Establish successful lactation

Table 8. Physiology of Breastmilk Production

DECREASED ESTROGEN AND PROGESTERONE levels after the delivery of the placenta stimulate anterior pituitary gland to produce prolactin acts on acinar cells to produce foremilk stored in collecting tubules. WHEN INFANT SUCKS posterior pituitary gland is stimulated to produce oxytocin causes contraction of smooth muscles of collecting tubules milk ejected forward LET DOWN or MILK EJECTION REFLEX hindmilk is produced.

1.

Implications of physiology of breastmilk production: a. Regardless of the mothers physical condition, method of delivery or breast size/condition, milk will be produced b. Lactation does not occur during pregnancy because estrogen and not progesterone are present and therefore, inhibits prolactin production. c. Lactation-suppressing agents are to be given immediately after placental delivery to be effective. d. Oral contraceptives are contraindicated in lactating mothers because they decreased milk supply. e. After pains are felt more by breastfeeding woman because of oxytocin production, they also have less lochia and experience more rapid involution.
40

f.

In emergency delivery when the uterus does not contract, put the infant to the breast. During initial contact in emergency delivery, determine whether the woman is a primi or a multi, the EDC and also assess the stage of labor. And if no sterile equipment is available to cut thecord, wrap the baby and the placenta together; never cut the cord unless sterile equipments are available.

2.

Advantages of breast feeding a. For mother: Economical in terms of time, money and effort. More rapid involution Less incidence of cancer in the breast, according to some studies b. For Baby Closer mother-infant relationship Contains aintibodies that protect against common illnesses Less incidence of gastrointestinal diseases Always available at the right temperature. Health teachings: a. Hygiene Wash breast daily at bath or shower time Soap or alcohol should never be used on the breast as they tend to dry and crack the nipples and cause sore nipples. Wash hands before and after feeding Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there is considerable breast discharge. b. Method as suggested by the la leche league: Side-lying position with the pillow under the mothers head while holding the bulk of beast tissues away from the infants nose. Stimulate the baby to open his mouth to grasp the nipples by means of the rooting reflex. Infant should grasp not only the nipple but also the areola for effective sucking motion. Effectiveness is ensured when: The babys mouth parts hike well up into the areola The mother feels after pains as the baby sucks. The other nipple flows with milk while baby is feeding on other breast. To prevent nipples from the becoming sore and cracked, infant should be introduce to the breast gradually. The baby should be fed for only 5 minutes at each breast at its feeding on the first day, increasing the time at each breast by 1 minute /day until the infant is nursing for 10 minutes at each breast each feeding, making a total feeding time of 20 minutes per feeding. For continuous milk production, at each feeding, the infant should be placed first on the breast he feed last in the previous feeding. This ensures that each breast will be completely emptied at every other feeding. if breasts are completely emptied, they completely refill again: if only half-emptied, will half refill and after sometime, will become insufficient. To brake away from the closed suction at the breast after feeding, insert a clean finger at the corner of the infants mouth to release the suction, then pull the chin down. This also helps prevents sore nipples. Feed as often as the baby is hungry, especially during trh first few days, because he is receiving colostrum, which is not very filling: however, it contains the only group of substances that can never be replicated by any artificial formula, the gama globulin (antibodies).
41

3.

 c.

d.

e.

d.

Advise the mother to learn how to relax during feedings because tension prevents good let-down. Associated problems Engorgement Feeling of tension in the breasts during the third postpartum day, sometimes accompanied by an increase in temperature (milk fever). The breast become full, feel tense and not, with throbbing pain. It last for about 24 hours and is due to increased lymphatic and venous circulation. Management: ** Advise use of firm-fitting brassiere for good support. It will not only decrease the discomfort from engorgement but also prevents contamination of the nipples and the areola. ** Cold compress is applied if mother does not intend to breast feed; warm compress is applied if she will breast feed. ** Breast pump is not used for breast. Done if mother is not going to breast feed, since either will only stimulate milk production. Sore Nipples are not contraindications to breastfeeding. Management: ** Expose nipples to air by leaving bra open for 10 to 15 minutes after a feeding ** When normal air drying is not effective, exposure to 20 watt bulb placed 12-15 inches away will cause vasodilation, increase circulation and promote healing. ** Do not use plastic liners that are found in some nursing bras because they prevent air from circulating around breast. Mastitis Inflammation of the breast Symptoms: ** Localized pain, swelling and redness in breast tissues ** Lumps in the breast ** Milk becomes scanty Management: ** Antibiotics, as ordered ** Ice compress ** Proper breast support ** Discontinue breastfeeding in affected breast. Nutrition Lactating mother should take 3000 calories daily and should have larger amounts of proteins (96 grams per day), Calcium, Iron, Vitamins A, B, and C. non-breastfeeding women can have the same requirements as in pregnancy. Contraindications: Drugs Oral contraceptives, atropine, anticoagulants, antimetablites, cathartics, tetracyclines. Insulin (Diabetes therefore, is not contraindicated), epinephrine most antibiotics, antidiarrheals and antihistamines are generally not contraindicated. Certain disease conditions, specifically tuberculosis because of the close contact between mother and baby during feeding. No TB germs, however, are transmitted thru breastmilk. Motivate use of Family Planning Methods The success of the Family Planning Program depends to the great extent on the motivation of both husband and wife. Physiologic Methods The oral contraceptives Action: Suppresses the pituitary gland, thus inhibiting ovulation. Types: Combined estrogen and progesterone in the same dosage each day for 20 days, starting on the fifth day of the menstrual cycle, after which it is discontinued and then resume on the fifth day of the next menstrual period.
42

1. a. b.

 c. d.

2. a.

Sequential estrogen alone for 15 days, then estrogen and progesterone for 6 days. Mini-pill taken continuously Side effects Same complaint of pregnant women because of estrogen and progesterone: Nausea and vomiting Headache and weight gain both due to fluid retention because of progesterone Breast tenderness Dizziness Breakthrough bleeding/spotting between periods Chloasma Contraindications: Breastfeeding Certain diseases: Thromboembolism because there is increased tendency towards clotting in the presence of estrogen. Diabetes mellitus and liver disease because estrogen tends to interfere with carbohydrate metabolism. Migraine; epilepsy, varicosities Cancer; renal disease, recent hepatitis Women who smoke more than 2 packs of cigarette per day. Strong family history of heart attack. Mechanical methods Interuterine Device (IUD) Specific action: Prevents implantation by setting-up a non-specific cell inflammatory reaction to the device. Inserted during a menstruation to ensure that the woman is not pregnant; septic abortion can result if she is pregnant. Side effects: Increased menstrual flow Spotting or uterine cramps during the first 2 weeks after insertion. Increased risk of infection when pregnancy occurs with the device in place, it need not be removed since it stays outside the membranes and, therefore, will not in any way harm the fetus. Diaphragm Specific action: a circular rubber disc that fits over the cervix and forms a barrier against the entrance of sperm Is initially inserted by a doctor who determines the depth of the vagina. Maybe coated with a spermicidal jelly or cream for double protection. Maybe washed with soap and water after use. Sperms remain viable in the vagina for 6 hours, so the device should be kept in place during such time, but should not stay more 24 hours because status of semen can lead to infection. Condom Rubber made of latex Specific action: sperms are deposited in the tip of the rubber sheath placed over an erect penis prior to coitus. Has the added potential of listening the chance of contacting sexually transmitted diseases (STD) Most common complaint of users: it interrupts the sexual act to apply Chemical Methods are spermicidals (kills sperm). E.g., jellies, creams, foaming tablets, suppositories. Biological Method Rhythm/Calendar/Ogiro-Koause formula Specific action: the couple abstains on days that the woman is fertile.
43

b.

c. 3.

4. a.

b.

procedure The woman charts her menstrual cycles for 12 continuous months in order to determine the shortest and longest cycles. The first fertile day is determined by subtracting 18 from the shortest menstrual cycle. E.g., If a womans shortest menstrual cycle is 26 days and her longest is 32 days. 26 32 18 - 11 = 8 21 her fertile period would be from the 18th to 21st day of her cycle, i.e., she should not have sexual intercourse during these days.

5. a.

b.

c.

Natural Family Planning (NFP) Periodic abstinence: Cervical mucus/Billings method Basis: the flow of mucus from the cervix of the uterus. Method: a woman can discern her fertile days based on her sensory and visual observation of the surgical mucus spinnbarkheit, intercourse is avoided 4 days prior to 3 days after the spinnbarkheit. Basal Body Temperature (BBT) Method: Involves observing the temperature of the woman at rest, free from any factor that may cause it to fluctuate (immediately upon waking up, before doing anything else soon as the temperature drops lightly and then increases (which means ovulations has taken place), she counts 3-4 days, after which sexual intercourse may be resumed. Sympto-Therman Method fertile and infertile days are determined after having established an accurate record of the 6 immediately preceding menstrual cycles then watching out for BBT fluctuations.

6. a. b.

Surgical Methods Tubal ligation The fallo[ian tubes are ligated in order to prevent passage of sperms. Menstruation and ovulation continue. Vasectomy Small incision made into each side of the crutum and the vas deference is cut and tied, blocking passage of sperms. Sperms production continues, only passage into exterior is prevented (sperms in the vas deference at the time of surgery may remain viable for as long as 6 months. Implication: Couple should still observe a form of contraception during this time to ensure protection against a subsequent pregnancy). Social Methods Abstinence Withdrawal or coitus interuptus

7. a. b.

RISK PREGNANCY I. Bleeding in Pregnancy

Table 9. Outline of classification

I.

First Trimester Bleeding

44

A.

Abortion 1. Spontaneous a. Threatened b. Imminent complete incomplete c. MIssed 2. Induced a. Therapeutic b. illegal

B.

Ectopic pregnancy 1. Tubal most common 2. Cervical 3. Ovarian 4. abdominal Second trimester Bleeding A. Hydatidiform mole B. Imcompetent Os Third Trimester Bleeding A. Placenta Previa B. Abruptio placenta

II.

III.

A.

Abortion Any interruption in pregnancy before the age of viability. 1. Spontaneous occurs from natural causes: blighted ovum/germ plasma defect (most common cause it is natures way of eliminating the birth of a congenitally defective baby): implantation of hormonal abnormality; following trauma, infection (e.g., Rubella, influenza) or emotional problems. a. Threatened Symptom: Bright red vaginal bleeding which is moderate in amount. Management: Complete bed rest for 24-48 hours; if bleeding will stop it usually stops within this time . Coitus is restricted for 2 weeks after bleeding has stopped in order to prevent further bleeding or infection. Endocrine/hormonal therapy Advise patient to save all pads, clots and expelled tissues. b. Imminent/inevitable Symptom: Bright red vaginal bleeding which is moderate in amount and accompanied by uterine contractions and cervical dilatations. Loss of the products of conception is inevitable. Management: Depends on whether it is Complete abortion all products of conception are expelled; bleeding is minimal and self limiting. No intervention is therefore needed, Incomplete abortion part of the conceptus, usually the fetus, is expelled, but membranes or placental fragments are retained. D & C is indicated as management.
45

c.

Missed abortion fetus die in uterus but is not expelled. Usually discovered at a prenatal visit when fundal height is measured and no increased is demonstrated or when previously heard fetal heart tones are no longer present. In 2 weeks time, signs of abortion should occur; otherwise, labor will have to be induced to prevent hypofibrinogenemia or sepsis.

2.

Induced is never allowed in the Philippines a. Therapeutic performed by a doctor in a controlled hospital or clinic setting for a medical or legal reason. Also known as medical, planned or legal abortion. b. Illegal ECTOPIC PREGNANCY any gestation located outside the uterine cavity. Signs and Symptoms Since the wall of the fallopian tube is not sufficiently elastic, it ruptures within the first 12 weeks of gestations as it can no longer give way for the growing fetus. a. Severe sharp, knife like, stabbing pain in either the right or left lower quadrant (in bleeding when there is no exit or egress of the blood from the body, pain is the outstanding symptom; this pain differentiates ectopic pregnancy from abortion). b. Rigid abdomen c. (+) Cullens sign bluish umbilicus d. Excruciating pain when cervix is moved from IE. e. Signs of shock: falling BP, PR more than 100 per minute, rapid RR, light headedness. Ruptured ectopic pregnancy is an emergency situation Management: a. Salpingotomy if fallopian tube can still be repaired and preserved, but pregnancy has to be terminated. b. Salpingestomy blood transfusion Nursing care combat shock: a. Elevated foot of the bed b. Maintain body heat by hot water bottles and blankets HYDATIDIFORM MOLE developmental anomaly of the placenta resulting in proliferation and degeneration of the chorionic villi Incidence: It is the most common lesion anteceding chriocarcinoma. It occurs most often in women. a. From low socioeconomic backgrounds with low protein intake b. Over 35 years and under 18 years of age. Signs and Symptoms: a. Because of rapid proliferation of placental tissues and, therefore, high levels of HCG: High positive urine test for pregnancy (that is why a positive pregnancy test cannot be considered a positive sign of pregnancy. Nausea and vomiting is usually marked Rapid increased in fundic height. b. Toxemia signs and symtoms appear before the 24th week of gestation. c. No fetal heart tones d. Vaginal bleeding seen as clear, fluid filled graped-sized vesicles.
46

B. 1.

2.

3.

C. 1.

2.

3.

Management: a. D & C to evacuate the mole b. Prophylactic course of Methotexate, the drug of choice for choriocarcinoma c. Urine testing for one year to find out if new villi are developing. Contraceptives (but not the pills) have to be used so as not to confuse the result. INCOMPETENT CERVICAL OS Cervix dilates prematurely. It is the chief cause of habitual abortion (3 or more concecutive abortions) Causes: a. Congenital development factors b. Endocrine factors c. Trauma to the cervix Signs and symptoms: a. Presence of show and uterine contractions b. Rupture of membranes c. Painless cervical dilatation Management: McDonald/Shirodkar-Barter procedure a cerclage procedure wherein purse-string sutures are placed around the cervix on the 14th 18th week of gestation. These are removed during vaginal delivery (if temporary), or the patient delivers by C/S (shirodkar method, since sutures are permanent). PLACENTA PREVIA Low implantation of the placenta so that it is in the way of the presenting part. Predisposing factors: a. Increasing parity b. Advanced maternal age c. Rapid succession of pregnancies Types: a. Low lying b. Partial c. complete Diagnosis Made by means of symptoms and ultrasound also known as Ultrasonic Echo Sounding or Sonar, uses intermittent waves of very high frequency (above audible range) to picture the fetus. Sound waves are projected towards the mothers abdomen, are reflected back and converted into electrical impulses and recorded on permanent graph paper. a. Preparation: Explain the procedure to the patient, informing her that it is painless and there are no known ill effects. Empty the bladder but ask the patient to take 6 glasses of water afterwards in order to diet the bladder. A full bladder displaces the bowel, therefore, permits better visualization of the pelvis and its contents. b. Clinical Uses: Diagnose pregnancy as early as 5-6 weeks gestational age. Can establish that the fetus is increasing in size and, therefore, can predict EDC. Can determine gestational age by measuring the biparital diameter of the fetal skull (if it is more than 8.5 cm, if more or less weight more than 2,500 gms); therefore, can diagnose intrauterine growth retardation, hydrocephaly. Can demonstrate size and growth rate of the amniotic sac; therefore can identify fully hydramnios, polyhydramnios, oligohydramnios. Can confirm presence, size and location of the placenta; therefore, is valuable in diagnosing previa and H mole.
47

D. 1.

2.

3.

D. 1.

2.

3.

 4.

Can diagnose multiple pregnancy Can visualize ascites, plycystic kidneys, ovarian cyst, etc. Can visualize ascites, polycystic third trimester and if in cephalic presentation.

First and most constant symptoms: painless bright red vaginal bleeding due to tearing of placental attachment as a consequence of the dilatation of the internal Os. Management: a. Complete bed Rest b. Monitor vital signs of the mother and the fetal heart rate c. Prepare oxygen and blood d. No attempt is made at doing internal examination. If ever it is to be done, it is done in a double set-up (done in the operating room wherein the patient has already signed the consent form; preop medications have been given abdominal prep has been done, etc. so that if the placenta is accidentally detatched because of the IE, CS can be done immediately). Complications: a. Hemorrhage b. Infection c. Pre-maturity ABRUPTIO PLACENTA premature separation of the placenta. Predisposing factors: a. Maternal hypertension or toxemia b. Increasing parity and maternal age c. Sudden release of amniotic fluid d. Short umbilical cord e. Direct trauma f. hypofibrinogenemia Signs and Symptoms: a. Severe, sharp, knife-like, stabbing pain, sign in the fundus b. Hard, cord-like uterus; rigid abdomen c. Sign of shock d. Concealed bleeding, if extensive, causes the uterus to lost its ability to contract. It becomes ecchymotic and copper-colored called Cruvalaine uterus, causing severe bleeding, since the uterus no longer has the ability to contract, hysterectomy will have to be done.

5.

6.

F. 1.

2.

II.

TOXEMIA/PREGNANCY INDUCED HYPERTENSION (PIH) a vascular disease of unknown cause which occurs anytime after the 24th week of gestation up to 2 weeks postpartum. It has the following triad of symptoms: Hypertension, edema, proteinuria (specifically albuminuria). A. 1. 2. 3. 4. 5. B. C. Predisposing factors: Age primis under 20 and over 30 years Gravida 5 or more pregnancies Low socioeconomic status (SES) Multiple pregnancy With underlying medical conditions, e.g., heart disease, hypertension or diabetes Pathogenesis: see next page (figure 17) Diagnosis: roll-over test assess probability of developing toxemia when performed between the 28 & 32nd week of pregnancy.
48

1.

Procedure: a. Patient lies in lateral recumbent position for 15 minutes until BP has stabilized. b. Then roll-over to back position c. BP is taken at 1 minute and 5 minutes after having rolled over. Interpretation if diastolic increases 20 mm./mg or more, patient is prone to toxemia. Table 10. Classification Acute toxemia symptoms appear 24th week of gestation a. pre-eclampsia 1. Mild 2. Severe b. Eclampsia Chronic hypertension with pregnancy Unclassified

2. I.

II. III.

D. 1.

Details Pre-eclampsia a. Underlying causes: Insufficient production of sides and platelets Generalized vasoconstriction and associated microangiopathy (disease of capillaries) Abnormal retention of sodium and water by body tissues b. Medical complications: Cerebrovascular hemorrhage Acute pulmonary edema Acute renal failure c. Types: Mild Pre-eclampsia Signs and symptoms: ** Sudden, excessive weight gain of 1-5 pounds, per week (earliest sign of pre-eclampsia). Due to edema which is persistent an found in upper half of the body (e.g., inability to wear the wedding ring). ** Systolic BP of 140, or an increase of 30 mmHg, or more and a diastolic of 90, or a rise of 15 mmHg or of more, taken twice, six hours apart. ** Proteinuria of 0.5 gm per liter or more Severe pre-eclampsia Signs and symptoms: ** BP of 160/110 mmHg ** Proteinuria or 5 gm/liter or more in 24 hours ** Oliguria of 100 ml or less in 24 hours (normal urine output in 24 hours = 1,500 ml) ** Cerebral or visual disturbances ** Pulmonary edema and cyanosis ** Epigastric pain (considered as aura to the development of convulsion) Management: Complete Bed rest Sodium tends to be excreted to a more rapid rate if the patient is at rest. Energy conservation is important in decreasing metabolic rate to minimize demands for oxygen. Lowered oxygen tension in toxemia is the result of vasoconstriction and decrease blood flow that diminishes the amount of nutrients and oxygen in the cells.
49

E. 1.

In any condition wherein there is a possibility of convulsions, bed rest should be in a darkened, non-stimulating environment with minimal handling. 2. Diet: a. For mild preeclampsia high protein, high carbohydrate, moderate salt restriction (no added table salt, including bagoong, patis and toyo, dried fish (e.g., daing and tuyo) canned goods, bottled drinks, preserved foods and cold cuts) For severe preeclampsia high protein, high carbohydrate and salt-poor (3 gms of salt per day)

b.

3.

Medications: a. Diuretics hourly urine output should be at least 20-30 ml (normally 50-60 ml per hour). E.g., chlorothiazide/Diuril. Pharmacologic effect: decrease reabsorption of sodium and chloride at the proximal tubules, thereby increasing renal excretion of sodium, chloride and water, including potsssium. Side effects: Fatigue and muscle weakness due to fluid and electrolyte imbalance Nursing care: closely monitor intake and output b. Digitalis if with heart failure pharmacologic action: increase the force of contraction of the heart, thereby decreasing heart rate. Should be given, therefore, if heart rate is below 6o/minute. (implication: take the heart rate before giving the drug.

c.

d. e. f.

Potassium supplements any patient receiving diuretics are prone to hypokalemia; if digitalis is given at the same time, hypokalemia increases the sensitivity of the patient to the effects of digitalis. Potassium supplements (e.g., banana) must be given to prevent arrhytmias. Barbiturates sedation by means of CNS depression Analgesics: anti-hypertensives antibiotics: anticonvulants Magnesium Sulfate drug of choice Actions: CNS depressant lessens possibility of convulsion Vasodilator decreased the BP causing a shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted. Dosage: 10 gms initially, either by slow IV push over 5-10 minutes, or deep IN, 5 gm/buttocks, then IV drip of 1 gm/hour (1 gm/100 ml D10W) IF: Deep tendon reflexes are present Respiratory rate is at least 12 beats per minute Urine output is at least 100 ml in 6 hours Antidote for Magnesium sulfate toxicity: Calcium gluconate 10 % IV to maintain cardiac and vascular tone. Earliest sign of magnesium sulfate toxicity; disappearance of the kneejerk/patellar reflex.

4. F.

Method of delivery preferably vaginal, but if not possible, CS will have to be done Prognosis: the danger of convulsion is present until 48 hours postpartum.

50

III.

DIABETES MELLITUS chronic hereditary disease which is characterized by hyperglycemia due to a relative insufficiency or lack of insulin from the pancreas which in turn, leads to abnormalities in the metabolism of carbohydrates, proteins and fats. Diabetogenic effects of pregnancy any woman who has no evidence of diabetes in the past develop abnormalities in glucose tolerance: Decrease renal threshold for sugar that is why it is not unusual to find sugar in the urine of pregnant women. Increased prodcution of adrenocorticoids, anterior pituitary hormone and thyroxines which affect carbohydrate and lipoid metabolism, this increasing carbohydrate concentration in the blood (hypoglycemia) Rate of insulin secretion is increased BUT sensitivity of the pregnant body to insulin is decreased, e.g., insulin does not seem to be normally effective during pregnancy. Attendants Risk: Toxemia Infection Hemorrhage Polyhydramnios Spontaneous abortion because of vascular complictions which affects placental circulation Acidosis because of nausea and vomiting, is the chief threat to the fetus in the uterus. Dystocia due to excessively large baby. Diagnosis made on the basis of Glucose Golerance Test Procedure: a. NPO after midnight b. 2 ml of 50 % glucose/ 3 kg of pregnant body weight is given IV (oral tablet not advisable because of known decreased gastric motility and delayed absorption of sugar during pregnancy) Categories Interpretation of results: a. If less than 100 mg % - normal b. If 100-200 mg % - possible gestational diabetes c. If more than 120 mg % - overt gestational diabetes

A. 1. 2.

3.

B. 1. 2. 3. 4. 5. 6. 7. C. 1.

2.

D. 1. 2. 3. E. 1. 2.

Categories to predict the outcome of pregnancy Class A GTT is only slightly abnormal; minimal dietary restriction; insulin not needed, fetal survival is high Class C E have 25 % perinatal mortality Class F therapeutic abortion (in other countries) may be justified Management: Diet highly individualized. Adequate glucose intake (1,600-2,200 calories) is necessary to prevent intrauterine growth retardation. Insulin requirements are likewise highly individualized, requiring close observation throughout pregnancy. Since the effects of the hormones are more pronounced during the second half of pregnancy, the insulin requirements during the 2nd and 3rd trimesters are, therefore, greater. a. Insulin is required to keep urine +1 for sugar (minimal glycosuria is necessary to prevent acidosis), but negative for acetone.
51

b. 3.

4. F. 1.

Long-acting insulin (Ultralente) will have to be change to regular insulin (Lente) during the last few weeks of pregnancy. Often delivered by CS because: a. Baby is typically larger or maybe in distress because of placental insufficiency. b. Severe metabolic imbalances in vaginal delivery can occur because of depletion of glycogen reserve in the liver and skeletal muscles by strenuous muscular exertion during labor. Maximum difficulty in controlling diabetes is during the early postpartum period because of the drastic changes in hormonal level. Infant of the Diabetic Mother (IDM). Is typical longer and weighs more because of: a. Excessive supply of glucose from the mother. b. Increased production of growth hormones from the maternal pituitary. c. Increase secretion of insulin from the fetal pancreas. d. Increased action of adrenocortical hormones that favor passes of glucose from mother to glucose. Congenital abnormalities are more often seen. Cushingoid appearance (puffy, but lim and letargic) More often born premature, so respiratory distress syndrome is common. Lose a greater proportion of weight than normal newborn bceause of loss of extra fluid. Are prone to the following complications: a. Hypoglycemia blood sugar level less than 30 mg %. It is the most common complication to watch for. > Cause: while inside the uterus, the fetus tends to be hyperglycemic because of maternal hyperglycemia. The fetal pancreas thus responds to the high glucose level by producing matching high levels of insulin, following delivery, the glucose level begins to fall because the baby has been severed from the mother. Since there has been previous production of high levels of insulin, hypoglycemia deevlops. Clinical symptoms: Shill, high-pitched cry Listlessness/litteriness/tremorrs Lethargy; poor suck Apnea; cyanosis Hypotonia; hypothermia Convulsions Consequence: hypoglycemia, if not treated can lead to brain damage and even death. Management: feed with glucose water earlier than usual or administer IV of glucose. b. Hypocalcemia serum calcium level of less than 7 mg %. Signs: same as hypoglycemia Management: Calcium gluconate to prevent hypocalcemis tetany.

2. 3. 4. 5. 6.

IV. A.

HEART DISEASE Classification: 1. Class I no limitation of physical activity. 2. Class II slight limitation of physical activity; ordinary activity causes fatigue, palpitation, dyspnea or angina. 3. Class III moderate to marked limitation of physical activity less than ordinary activity causes fatigue, etc. 4. Class IV unable to carry on any activity without experiencing discomfort.
52

B.

Prognosis: 1. Classes I & II normal pregnancy and delivery. 2. Classes 3 & 4 poor candidates. Signs and Symptoms: 1. Because of increased total cardiac volume during pregnancy, heart murmurs are observed. 2. Cardiac out put may become so decreased that vital organs are not perfused adequately; oxygen and nutritional requirements are not met. 3. Since the left side of the heart is not able to empty pulmonary vessels adequately, the latter become engorged, causing pulmonary edema and hypertension, moist cough in gravidocardiacs, therefore, is a danger sign. 4. Liver and other organs become congested because blood returning to the heart may not be handled adequately, causing the venous pressure to rise. Fluid then escapes through the walls of engorged capillaries and cause edema or ascites. 5. Congestive heart failure is a high probability also because of the increased cardiac output during pregnancy: dyspnea, exhaustion, edema, pulse irregularities, chest pain on exertion and cyanosis of nailbeds are obvious. D. 1. 2. 3. Management consider the functional activity of the heart Bed rest especially the 30th week of gestation to ensure that pregnancy is carried to term or at least 36 weeks. Diet should gain enough, but not too much a it would add to the workload of the heart. Medications: a. Digitalis b. Iron preparations, e.g., Fer-in-sol or Feosol Anemia should be prevented because the body compensates by increasing cardiac output, thus further increasing cardiac workload. Classes III & IV are not put on lithotomy position during delivery to avoid increasing venous return. The semi-sitting position is preferred to facilitate easy respiration. Anesthetic of choice of caudal anesthesia for effortless, pushless and painless delivery. Remember, gravidocardiacs are not allowed to push with contractions (to prevent valsalva maneuver which increases venous return to an already weak, damaged heart). Low forceps, therefore, is the best method of delivery. Ergotrate and other oxytocis, scopolamine, diethylstilbestrol and oral contraceptives are contraindicated because they cause fluid retention and promote thromboembolization. Most critical period the period immediately following delivery because the 30% to 50 % increase in the blood volume during pregnancy will be reabsorbed into the mothers circulation in a matter of 5-10 minutes and the weak heart must make rapid adjustment to this change.

C.

4.

5.

6.

7.

V. A. 1.

MULTIPLE PEGNANCY (Twin pregnancy) Classification: Monozygotic/identical twins begin with a single ovum and sperm, but in the process of fusion or in one of the first cell division, the zygotes divide into two identical individuals. a. Characteristics: Always of the same sex With two amnions, 1 chorion, 2 umbilical cords ad 2 placentas fused as one. b. Incidence a chance occurrence: More frequent among non-whites More frequent among young primis and old multis.
53

2.

Diszygotic/fraternal two separate ova are fertilized by two different sperms. They are actually siblings growing at the same time in utero. a. Characteristic: May or may not be of the same sex. With two amnions, two chorions, 2 placentas and 2 umbilical cords. b. Incidence familial maternal pattern of inheritance. Suspect multiple pregnancy if: 1. Faster rate of increaed in uterine size 2. On quickening, there are several flurries of action in different abdominal positions. 3. On auscultation, 2 sets of fetal heart tones are heard. 4. There are marked weight gains, not due to toxemia or obesity. Complications: 1. Toxemia 2. Polyhydramnios 3. Anemia

B.

C.

4.

Abruptio placenta 5. Prematurity 6. Postpartum hemorrhage

VI. A.

1.

INSTRUMENTAL DELIVERIES Forceps delivery use of metal instruments (e.g., Simpson, Elliot, Piper for Breech presentation) in order to extract the fetus from the birth canal. Forceps are applied when the fetal head is at the perineum (+3 or +4 station) and the sagittal suture line is in an anteroposterior position in relation to the outlet. Purposes: a. Shorten scond stage of labor primary purpose because of: Fetal distress Maternal exhaustion Maternal disease cardiac, pulmonary complications, hemorrhage Ineffective pushing to anesthesia c. Prevent excessive pounding of fetal head against the perineum (e.g., low forceps or preemies) c. Poor uterine contractions or rigid perineum. Prerequisites: a. Pelvis should be adequate; no disproportion b. Fetal head is deeply engaged c. Cervix is completely dilated and effaced d. Membranes have ruptured e. Vertical presentation has been established f. Rectum and bladder are empty g. Anesthesia is given for sufficient perineal relaxation and to prevent pain Types: a. Low b. mid Complications: a. Forceps Marks are normal and noticeable only for 24-48 hours b. Bladder or rectum injury, facial paralysis, ptosis, seizures, epilepsy, cerebral palsy are actually rare. Cesarean Section (CS) Indications: a. Cephalopelvic disproportion (CPD) most common reason b. Severe toxemia, placental accidents, fetal distress
54

2.

3.

4.

B. 1.

c. 2.

Previous classis CS elective CS done to prior onset of labor pains

Types: a. Low segment the method of choice. Incision is made in the lower uterine segment which is the thinnest and most passive part during active labor. Advantages: Minimal blood loss Incision is easier to repair Lower incidence of postpartum infection No possibility of uterine rupture. b. Classic vertical incisions. Recommending in: Bladder or lower uterine segment adhesions resulting from previous operatons Anterior placenta previa Tranverse lie Preoperative care patient for CS is both a surgical and an obstetrical patient; a. Check vital signs, uterine contractions and fetal heart rate. b. Physical examination; routine laboratory test, blood typing and cross-matching c. Abdomen is shaved from the level of xyphoid process/below the nipple line, extending out to the flanks on both sides up to the upper thirds of the thighs. d. Retention catheter is inserted to constant drainage to keep the bladder away from the operative site. e. Preoperative medication usually only Atropine sulfate. No narcotics are given in order to prevent respiratory in the newborn. Postoperative care: a. Deep breathing, coughing exercise, turning from side to side b. Ambulate after 12 hours c. Monitor vital signs d. Watch for signs of hemorrhage inspect lochia: fell fundus (when boggy, massage with proper abdominal splinting and give analgesics as ordered). e. Breastfeeding, if desired, should be started 24 hours after delivery (anesthetic can be transmitted through breastmilk) Most common complication: Pelvic thrombosis. INDUCED LABOR to bring about labor either by amniotomy or drugs (oxytocin or prostaglandin) before the time when it would have occurred spontaneously or because it does not occur apontaneously. Indications: Maternal a. Toxemia b. Placental accidents c. Premature rupture of BOW Fetal a. b. c. d. Diabetes terminated about 37 weeks GA if indicated Blood incompatibility with rising titer Excessive size Post maturity

3.

4.

5. VII.

A. 1.

2.

B. 1.

Prerequisites: No CPD
55

2. 3. 4. C. 1.

Fetus is viable survival is decreased if below 32 weeks GA Single fetus in longitudinal lie and is engaged Ripe cervix fully or partially effaced; dilated at least 1 2 cm. Procedure: Oxytocin administration: a. 10 IU of Pitocin in 1000 ml of D5W at a slow rate of 8 drops/minute given initially. If no fetal distress is observed in 30 minutes, infusion rate is increased 16-20 drops per minute.

b. c.

Amniotomy will be done when cervical dilatation reaches 4 cm. Check FHR and quality of fluid after amniotomy. Nursing Care: Primary concern: Monitor intensity of uterine contractions. Remember: if uterine contractions are unduly sustained, uterine rupture can occur. Monitor flow rate regularly Turn off IV drip if with abnormalities in FHR and uterine contractions. Watch out for: Hypertension oxytocin is a vasoconstrictor Antidiuresis leading to water intoxication ** Headache and vomiting ** Convulsions, coma, and even death

2.

Prostaglandin administration: a. Route: Either oral or IV, never IM, because it causes tissue irritation. b. Effect: compared to oxytocin, the onset of contraction is slower. INFECTIONS Syphilis Cause: Treponema Pallidum a spirrochete which enters the body during coitus or through cuts and other breaks in the skin or mucous membrane. Treatment:: 2.4-4.8 million units or penicillin (if allergic, 30-40 gm of erythrocin) will usually prevent congenital syphilis in the newborn because Penicillin readily crosses the placenta. If untreated, syphilis can cause midtrimester abortion. CNS lesions in the newborn or even death. The newborn with congenital syphylis a. Signs and symptoms: jaundice at two weeks of life first sign of the disease anemia and hepatosphenomegaly snuffles (persistent rhinorrhea coppery patches; condylomas; psuedoparalysis due to bone inflammation if untreated, can progress on to deformed bones, teeth, nose, joints and CNS syphilis. b. Management: Penicillin IM for 10 days or one long-acting Penicillin (Penadur LA) Rubella/German Measles Incidence: a. Mothr the earlier the mother contacted the disease, the greater the likelihood the baby will be affected. The rubella virus slows down divisions of infected cells during organogenesis. b. Newborn can carry and transmit the virus for as long as 12-24 months after birth.
56

XI. A. 1.

2.

3.

B. 1.

2.

Signs and symptoms of Congenital Rubella Syndrome: a. Low birth weight; jaundice; petechiae; anemia, hepatosplenomegaly; b. Classis sequelae: Eyes: chorioratinitis, cataract, glaucoma Heart: Patent Ductus Arteriosis, stenosis, coarctation Ear: never deafness Dental and Facial clefts

thrombocytopenia;

IX. A. B.

BLOOD INCOMPATIBILITY Excessive destruction of fetal red cells which occurs when the: When the mother is Rh negative and the fetus is Rh positive ( because the father is either a homozygous or a heterozygous Rh positive) Mother is type O and the fetus is either type A or B (because the father is either Type A or B) MISCELLANEOUS RISK FACTORS Age Maternal and infant mortality rates tend to be high in cases in which the mother is younger than 15 and older than 40. Adolescent pregnancy is a high-risk pregnancy from both a physical and a psychosocial standpoint, physical because of rapid growth of both the pregnant adoslescent and her fetus, causing possible depletion of nutritional reserves. Psychosocial, because adolescence is a crisis period by itself, compunded by the situational crisis of pregnancy, plus the fact that most pregnant adolescents are unwed adolescents. Most common problems of pregnant adolescents: Toxemia Iron-deficiency anemia Advanced age is a precipitating factor in: a. Placental accidents b. Toxemia c. Uterine atony or inertia d. Varicosities; hemorrhoids e. Low birth weight babies f. Chromosomal abnormalities, e.g., Downs syndrome/Trisomy 21/mongolism, commonly associated with menopause: Mechanism a transitional phase, called the climateric, heralds the onset of menopause. During this 1-2 year period, the monthly menstrual flow occurs less frequently, is irregular and diminished in amount. Ovulatory and anovulatory periods, however, occur (that is why contraceptive methods are advised until the menses have been absent for at least six continuous months). After there have been no periods for one year, menopaused is said to have occurred. Classic signs: Vasomotor changes due to hormonal imbalance: ** Hot flushes (head, neck, upper thorax) ** Excessive sweating especially at night. Emotional changes insomnia, headache, palpitations, nervousness, apprehension, depression Tendency to gain weight more rapidly Tendency to loss height because of osteoporosis (dewager hump) Arthralgins and muscle pains Loss of skin elasticity and subcucataneous fat in labia folds Artificial menopause/surgically included menopause results from:
57

X. A. 1.

2.

 B.

Obphorectomy or irradiation of ovaries Panhysterectomy (mere hysterectomy may not lead to menopause since ovaries are still intact: only menstruation will be absent)

Parity First pregnancy is the period of highest risk. Risk increases steadily from gravida 5 and above, especially when the mother is over 40 years of age. Birth interval a subsequent pregnancy within 3 months of a previous delivery is highrisk, as much as a birth interval of more than 5 years. Weight A prepregnant weight of less than 70 pounds or more than 180 pounds is a risk factor. A weight gain during prenancy of leass than 10 pounds can lead to low birth weight babies, prematurity, abortion, stillbirth and toxemia. A weight gain of more than 30 pounds during pregnancy maybe a sign of toxemia, diabetes, polyhydramnios, H-mole or multiple pregnancy. Height of short stature (less than 4 feet 10 inches) could mean a contracted pelvis or cephalopelvic disproportion. THE NEONATE

C.

D. 1. 2.

E.

DEFINITION: The first 28 days of life. PRINCIPLES OF NEWBORN CARE I. Establish and maintain a patent airway A. Never stimulate a baby to cry unless secretions have been drained cut. B. The position should be one that promotes drainage of secretions (head lower than the rest of the body) EXCEPT when there are signs of increased intracranial pressure (vomiting; bulging, tense fontanelles; abnormally large head; increased BP, decrease PR and HR and widening pulse pressure; shrill, high pitched cry), in which case, the head should be higher than the rest of the body. C. Suction the newborn properly: 1. Turn the babys head to one side 2. Suction gently and quickly prolonged and deep suctioning of the nasopharynx during the first 5-10 minutes of life will stimulate the vagus nerve (located in the esophagus) and cause bradycardia. 3. Suction the mouth first before the nose when suctioning the nose, the stimulation of the nasal mucousa will cause reflex inhalation of pharyngeal material into the trachea and bronchi, causing aspiration. 4. To test for patency of the airway, occlude one nostril at a time (remember: newborns are nasal breathers). If the newborn struggles when a nostril has been occluded, additional suctioning is indicated. II. Maintaining appropriate body temperature. Chilling will increase the bodys need for oxygen. The newborn suffers large losses of heat (cold stress) because he is wet at birth, the delivery room is cold, he does not have enough adipose tissues and does not know how to shiver. Effects of cold stress: Metabolic acidosis one of the ways by which heat is produced in the newborn is by increasing metabolism. When this occurs, fatty acids accumulate because of the breakdown of brown fat (seen only in newborn) Hypoglycemia due to the use of glucose stored as glycogen. a. Dry the newborn immediately b. Wrap him warmly
58

c. III.

Put him under a drop light

Immediate assessment of the newborn a. Apgar score standardized evaluation of the newborn condition. Done at one minute after birth to determine the general condition and then at 5 minutes to determine how well the newborn is adjusting to extrauterine life. Table II. Apgar score

SIGN 1. Heart rates

0 Absent

1 100 <

2 > 100

2. Respiratory Effort Absent Weak cry Good, strong cry 3. Muscle tone limp, flaccid flexion or well-flexed extrimities extrimities 4. Reflex irritability No response Grimace; sneeze; good & strong cry weak cry 5. Color Pale, blue extremities Pink all over blue, body pink

Most critical observation The general attitude of the baby at birth is that of flexion 1. Interpretation of results: a. 0-3 the baby is in serious danger and needs immediate resuscitation. b. 4-6 condition is guarded and need more extensive clearing of the airway c. 7-10 baby is in the best possible health Assessment or gestational age 1. Methods of estimating gestational age: a. Mothers LMP (Nageles Rule) b. Fundic height (McDonalds method) c. Batholomews Rule d. Time quickening is first felt e. Time fetal heart tones are first heard f. Ultrasound g. Assessment of newborn at birth Table 12. Clinical criteria for gestational age assessment

b.

SIGN 1. 2. Breast nodule diameter 3. Scalp hair 4. Earlobe

TILL 36 WKS Anterior transverse creases only 2 mm

37 38 WKS occasional creases anterior 2/3 4 mm

39 WKS sole covered with creases 7 mm

fine & fuzzy pliable, no cartilage

fine & fuzzy some cartilage

coarse & silky stiffened by thick cartilage

59

5. Testes and scrutum

testes in lower scrutal sac

intermediate

testes pendulous; scrutum full with extensive rugae

c. IV.

Cephalometry measurement of diameters of the skull: suboccipitobregmatic, biparietal, occipitofrontal, occipitomental, bitemporal

Proper identification of the newborn must be done in the delivery room before bringing to the nursery. Footprints are said to be the best way by which we identify newborns. Nursery Care Check identification band Take anthropometric measurements: 1. Length average: 50 cm (20 inches) = 19 to 21 inches (47.5 53.75 cm) 2. Head circumference 33 to 35 cm 3. Chest circumference 31 to 33 cm 4. Abdominal circumference 31 to 33 cm take the temperature at birth is 37.2 Degrees Celsius or 99 degrees Fahrenheit, but because of the evaporation from the moist skin and the cold delivery room, will stabilize in 8 hours time and must be maintained at 35.5 Degrees to 36.5 Degrees Celsius (97 Degrees to 99 Degrees Fahrenheit) so as to prevent hypoglycemia and acidosis due to hypothermia. Axillary and rectal temperatures are approximately the same immediately following birth but the rectal route is prepared in order to check patency of the anus.

V. A. B.

C.

D.

Specific Nursing Actions: 1. Give initial oil bath to clean the baby of blood, mucus and vernix. 2. Dress the umbilical cord. Inspect for the presence of 2 arteries and 1 vein. Suspect a congenital anomaly if blood vessels are not complete; a more thorough physical assessment is indicated and closer observation in an ICU is done. 3. Credes prophylaxis prophylactic treatment of the newborns eyes against gonorrheal conjunctivitis (opthalmic neonatorum) which the baby acquires as he passes through the birth canal of his motherwho has untreated gonorrhea: a. Wipe the face dry. b. Shade the eyes from light and open 1 eye as a time by exerting gentle pressure on the upper and lower lids. c. 2 drops of 1 % silver nitrate are instilled one at a time into the lower conjunctival sac (be careful not to drop on the cheeks because parents may worry about the stains) d. wash silver nitrate away with sterile NSS after 1 minute to prevent chemical conjunctivitis (inflammation, edema, purulent discharge) e. penicillin/chloromycetin/terramycin, opthalmic ointment may be used since it does not irritate the eyes (although the baby may develop sensitivity at an early age). Apply from the inner to the outer canthus of the eye. 4. Vitamin K administration a. Rationale: Vitamin K facilitates production of the clotting factor, thus preventing bleeding. But vitamin K is synthesized in the presence of normal bacterial flora in the intestines. Since the newborns intestines are still relatively sterile, therefore,
60

b.

they will not be able to synthesize vitamin K; that is why synthetic vitamin K is given to prevent hemorrhage. Method: 1 mg Aquamophyton (generic name is phytonadyone) is injected IM into the lateral anterior thigh (vastus lateralis). In children below 12 months of age who have not yet learned how to walk, this is the preferred site of injection because gluteal muscles are not fully developed.

5.

Weight-taking a. Average birth weight 6 to 7.5 pounds 3 to 3.4 kgs = 3,000 to 3,400 gm b. Arbitrary lower limit below which the newborn is said to be of low birth weight: 5.5 pounds = 2.5 kgs = 2,500 gm c. Ideal procedure weight the clothes first put on te4h bays clothes weight the baby with his clothes on subtract the weight of the clothes from the total weight of the baby and his clothes d. physiologic weight loss of 5 to 10 % of birth weight (6 10 0z) during the first 10 days of life because the newborn: Is no longer under the influence of maternal hormones Voids and passes out stools Has limited intake Has beginning difficulty establishing sucking Feeding a. Initial feeding is a test feeding consisting or an ounce of sterile water (glucose water has been found to be irritating to the lungs if aspirated); is given to find out if the newborn can swallow without aspirating. b. Subsequent feedings preferably given by demand.

6.

D.

Physical Assessment: 1. Pulse normally irregular and 120-160 per minute. Apical pulse (stethoscope below the left nipple) is recommended since radial pulses are not ordinarily palpable (if prominent, in fact, may be a sign of congenital heart anomaly) 2. Respiration are gentle, quiet, rapid but shallow; normally 30-60 per minute. Largely diaphragmatic and abdominal (watch for the rise and fall of the chest and abdomen). Blood pressure not routinely measured in newborn unless coarctation of the aorta is suspected. a. Normal values: At birth = 80/46 mm Hg After 10 days = 100/50 mm Hg b. Size of cuff in children: must not be more than 2/3 the size of the extremity (will result in false BP) nor less than the length of the extremity (will result in high BP). c. Procedure flush method: Cuff is applied to an extremity Extremity is elevated and an elastic bandage is wrapped around the distal portion of the extremity Slowly inflate the cuff up to 100 mmHg, then remove the bandage (extremity is expectedly pale) Slowly deflate the cuff, while watching the pale extremity As soon as the extremity turns pink (flushes), read the manometer. Only one reading can be obtained, the average between the diastole and the systolic pressure, called flush pressure (therefore, is normally 60)
61

3.

4.

Skin a.

Color normally ruddy because of the increased concentration of RBCs and the decreased amount of subcutaneous fat Acrocyanosis body pink, extemities blue. Normal during the (first 24-48 hours) of life. Generalized mettling I common due to an immature circulatory system Pallor due to anemia which results from excessive blood loss when cord is cut, inadequate blood flow from the cord to infant at birth, inadequate iron stores because of poor maternal nutrition. May also be due to blood incompatibility. Gray color indicates infection Jaundice yellowish discoloration of the skin and sclera: Cause: Inability of the newborn to conjugate bilirubin (figure 18) Normal values: 1. Total serum bilirubin = 15 mg% a. Direct bilirubin = 1.7 b. Indirect bilirubin = 13.3 Most accurate method of assessing presence of jaundice: Use natural light and blanch skin on the chest or tip of the nose Physiologic jaundice from the 2nd to the 7th day of life ** Breastfeed babies,however, have longer physiologic jaundice because human milk has pregnanediol which depresses the action of glucoronyl transferase (the enzyme responsible for converting indirect bilirubin to direct bilirubin)

Figure 18. Normal Process of RBC Breakdown

DESTROYED RBCs

62

release

HEME

GLOBIN

breakdown

IRON (roused by the body; not involved in jaundice

PHOTOPORPHYRIN

further broken down INDIRECT BILIRUBIN (fat-soluble; cannot be excretedby the kidney)

converted by liver enzyme glucororyl transferase DIRECT BILIRUBIN (water-soluble; can be excreted by the kidneys) Harlequin sign because of immaturity of circulation, an infant who has been lying on his side will appear red on the dependent side and pale on the upper side. Mongolian spots slate-gray patches soon across th sacrum/buttocks and consist of collection of pigment cells (melanocytes). Disappear by school age. Soon only among Southern European, Asian, and African children. Lanugo fine, downy hair that covers the shoulders, back and upper arms. Desquamation drying of newborns skin Petechiae on the neck due to increased intravascular pressure during delivery Milia unopened sebaceous glands found on the nose, chin and cheeks; disappear spontaneously by 2-4 weeks.

5.

Head largest part of the infants body (1/2 of his total length) a. forehead is large and prominent b. chin is receding and quivers when startled or crying c. fontanelles are either sunken (a sign of dehydration) or bulging (sign of increased intracranial pressure)
63

d. e.

Suture lines should neither be separated nor fontanelles prematurely closed (craniocyanostosis; leads to mental retardation) Craniotabos localized softening of the cranial bones; can be indented by pressure of a finger. Corrects itself without treatment after some months. More common among first-borns because of early lightening.

Table 13. Comparison between Caput and CephalhEmatoma INDICATIONS Definition Location CAPUT SUCCEDANEUM Edema of the scalp Presenting part of the head CEPHALHEMATOMA collection of blood Between periesteum of Skull bone and the bone itself Confined to an individual bone; does not cross suture lines Rupture of capillaries due to pressure takes several weeks

Extent of involvement

Both hemispheres

Cause

Pressure (as in prolonged Labor) On or about the third day

Period of absorption (most significant difference) Treatment

none

None; support the Anxious parents

6.

Eyes a. b.

Method of assessment: Put infant on upright position Characteristics: Cry tearlessly during the first 2 months because of immature lacrimal ducts Cornea should be round and adult-sized Pupils should be round, not key-holed

7.

Ears level of top part, of external ear should be in the line with outer canthus of the eye. If set lower, maybe a sign of kidney malfunction or Downs syndrome. Nose may appear large for the face; there should be no septal division Mouth a. Should open evenly when crying; if not, suspect cranial nerve injury b. Tongue appears large c. Palate should be intact; no breaks in the lips d. Epsteins pearls 1 or 2 small, round, glistening cysts seen on the palate; due to extra load of calcium while in the utero e. A tooth may be seen; if loose, should be extracted to prevent aspiration on when feeding f. Oral thrush white or gray patches on the tongue and sides of the cheeks due to Candida albicans acquired during passage of the baby through the birth canal of the mother with untreated moniliasis; also known as oral moniliasis. Neck
64

8. 9.

10.

a. b. c.

Thyroid gland is not palpable Appears soft and chubby and crossed with skin folds Head should rotate freely on the neck and flex forward and back

11.

Chest as large as, or smaller than the head: a. Should be symmetrical b. Breast maybe engorge as a result of maternal hormones c. Witchs milk thin watery fluid also due to maternal hormones Abdomen: a. Liver, spleen and kidney are palpable at birth. Liveris about 1-2 cm below the right costal margin. b. Normally dome-shaped; if scaphoid, suspect Diaphragmatic Hernia. Anogenital area a. Take note of the time meconium is first passed (it should be within the first 24 hours of life) b. Female genitlia: may have swollen labia and drops of blood due to maternal hormones c. Male genitalia: Scrotum maybe edematous also due to the maternal hormones Foreskin should be retracted to test for phimosis (tight foreskin) Testes should be pesent; if not descended, the condition is called cryptoorchidism (repair of undescended testes is called orchidopexy) Circumcision maybe done to discharge from t eh nursery, preferably by the end of the first week. Pocedure: ** Vitamin K injected IM ** Infant is restrained; penis is cleansed with soap & water ** Yellen clamp is used ** Petrolatum gauze dressing is applied to prevent adherence of circumcised site to the diaper while applying pressure to prevent bleeding Nursing care: ** Check hourly for bleeding (most common complication) during the first day. If small amount of bright red blood is observed, apply gentle pressure to the area with a sterile gauze pad. ** Do not attempt to remove exudate which persist for 2-3 days. Just wash with warm water ** Diaper must be pinned loosely during the first 2-3 days when the base of the penis is tender Back on prone, appears flat (curves start to form only when sitting or walking has been achieved) Extremities a. Arms and legs are short; hands are plump and clenched into fists b. Should move symmetrically c. Abnormalities: Erb-Duchonne paralysis/Brachial plexus injury Causes: ** Lateral traction exerted on head and neck during delivery of the shoulders in vertex presentation
65

12.

13.

14.

15.

**

Excessive traction on the shoulders during breech extraction, especially when the arms are extended over the head Signs and symptoms: ** Inability to abduct arm from the shoulder, rotate arm externally or supinate forearm ** Absent Moro reflex on affected arm ** Some sensory impairment in the outer aspect of affected arm management: Abduct the affected arm in external rotation position with the elbow flexed

Congenital hip dislocation/dysplasia Signs and symptoms: ** Assist in replacing head of the femur into the acetabulum of the hip bone by using 3 diapers instead of one, or by putting a pillow between the thighs to maintain abduction of the thighs and flexion of the hip and knee joints. ** (Hip spica cast is applied at the later age) before the infant starts to walk. Cast extends from the waistline to below the knee of the affected leg and above the knee of the unaffected leg

E. 1.

Systemic evaluation Cardiovascular system a. Major differences in fatal circulation: Exchange of oxygen and carbon dioxide takes place in the placenta, not in the fetal lungs. Because little blood goes to the fetal lungs, pressure in the left side of the fetal heart is less than the pressure in the right side of the fetal heart. Presence of fetal accessory structures: Foramen ovale bypasses the pulmonary circulatory system since it is the opening between the right and left atria. Ductus arteriosus communication between the pulmonary artery and the aorta Ductus venosus communication which bypasses the liver Umbilical vein carries the most highly oxygenated blood Umbilical arteries carry deoxygenated blood

Figure 19. Fetal Circulation

SVC

brain, heart & upper Half of the body

66

Ascending aorta

RA

PO

LA

Ductus Arteriosus IVC Liver Lungs Descending aorta

Ductus venosus

Pulmonary Artery Aorta LV

RV

Extremities and lower half of the body Umbilical vein Umbilical cord PLACENTA

b.

c.

Neonatal/ adult circulation as soon as breathing has been initiated, oxygenation now takes place in the newborns lungs. The change from fetal to neonatal circulation is, therefore, associated with lungs expansion, causing pressure in the left side of the newborns heart to become higher compared to pressure in the right side of the newborns heart Increased pressure on the left side of the newborns heart results in: Closure of the foramen ovale Change of the ductus arteriosus into a mere ligament (ligamentum arteriosum) The decreased pressure on the right side of the newborns heart causes the ductus venosus to become a mere ligament (ligamentum venosum) Since no more blood goes through the umbilical vein and arteries, these blood vessels atrophy and degenerate. Blood values are all high in the newborn period as a response to the pulmonary circulation: Red Blood Cells 6 million/ml3 Hemoglobin = 17-18 gm% Hematocrit = 52% White blood cells = 15,000-45,000 per ml3. A high WBC count during the newborn, therefore, is not a sign of infection: with or without infection, all newborn have high WBC count.

2.

Gastrointestinal tract differences in stools:

67

a. b. c.

d. 3.

Meconium sticky, tarlike, blackish-green odorless material formed from mucus, vernix, lanugo, hormones and carbohydrates that accumulated while in utero Transitional on the 2nd to the 10th day of life in response to the feedings pattern; are slimy, green and loose, resembling diarrhea to the untrained eye Breastfed golden yellow, rushy, more frequent (3-4 times/day) and sweetsmelling because breaskmilk is high in lactid acid which reduces amount of putrefactive organisms. Bottlefed pale yellow, firm, less frequent (2-3 times/day) and with more noticeable color

Urinary system newborns should void within the first 24 hours of life a. Female newborns form a strong stream when voiding b. Male newborns form a small projected are when voiding. If not, suspect a defect in the urethral meatus: Hypospadias urethral opening loacted in the ventral (under) surface of the penis Epispadias urethral opening located in the dorsal (above) surface of the penis Management: ** Inspect for eryptoorchidism often found associated with hypo/epispadias ** Mastectomy is done to establish better urinary function ** When the chil is older 12-18 months), adherent chordae (fibrous bands that cause the penis to curve downward) may be released surgically. If repair will be extensive, surgery might to delayed until 3-4 years old. ** Child should not be circumcised because at the time of repair, the surgeon may wish to use a portion of the foreskin ** Surgical correction is done before school age so that the child appears normal to his schoolmates. Autoimmune system a. Type of immunity transferred from mother to newborn: passive natural immunity b. Newborns have antibodies from the mother against poliomyelitis, diphtheria, tetanus, pertussis, rubella and measles (present in the infant for one year). But little or no immunity against chickenpox (that is why chickenpox is often fatal in the newborn).

4.

c. 5.

Newborns have difficulty forming antibodies until 2 months of age (that is why immunizations are started at 2 months).

Neuromuscular system a. Blink reflex rapid closure when strong light is shone; always present b. Feeding reflexes: Rooting reflex head will turn to the direction where cheek is stroked near the corner of the mouth; will help infant find food; disappears by (6 weeks) of age when infant is already capable of seeing things past the visual midline Sucking reflex anything place between the lips will be sucked; disappears by (6 months). IMPORTANT: sucking reflex disappears immediately if not stimulated regularly. IMPLICATION: any infant who will not be put on NPO should be given a pacifier not only for psychological reasons, but also to prevent premature disappearance of the sucking reflex.

68

 c.

d.

e. f. g.

Extension reflex anything placed on the anterior portion of the tongue will be spit out; disappears by 4 months of age when infant is about ready for semi-solid or solid foods. Swallowing reflex anything placed at the back of the tongue will be swallowed; will never disappear. Tonic neck reflex (TNR))/fencing reflex/ boxer reflex when on his back, the infants arm and legs are extended on the side where the head is turned, while the arm and the leg on the opposite side are flexed; disappears by 2-3 months Babinski reflex when side of the sole is stroked with a J from heel upward, the infant will run out his toes; starts to disappear by 3 months of age. (if the adult sole is stroke, the adult will curve in his toes). Landau reflex when on prone, the newborn should demonstrate some muscle tone; a test of spinal cord integrity Palmar or plantar grasp/step-in-place reflexes accesory reflexes Moro reflex singular most important reflex indicative of neurological status. If the bassinet is jarred or the infants head is allowed to drop backward in supine position (change infants equilibrium), the infant will abduct and adduct his arms. Disappears by 4-5 months.

6.

Senses all are functional at birth: a. Sight all newborns can see at birth, although they cannot see object past the visual midline (not until 6-8 weeks) the visual field is 20-22 cm or 9 inches. b. Hearing as soon as amniotic fluid has been absorbed, the newborn can already hear. c. Taste as soon as secretions have been suctioned, newborns can already taste. d. Smell as soon as the nose has been cleared of mucous and fluid, newborns can smell. e. Touch the most developed of all the senses. Discharge Instructions Bathing maybe given anytime convenient for the parents as long as it is not within 30 minutes after a feeding because the increased handling during bathing can cause regurtation. Sponge baths are done until the cord falls off (7th 14th day) Cord care a. Fold down diapers so that cord does not get wet during voiding. b. Dab rubbing alcohol (70%) once or twice a day c. Small, pink granulating area may be seen on the day the cord falls off. If it remains moist for a week, advise mother to bring baby to the doctors clinic where cautery with silver nitrate stick will be done to speed healing. Nutrition a. Recommended daily allowances Calories 120 cal/kg body weight (KBW) = 50-55 cal/lb body Weight = more or less 380 cal/day Proteins 2.2 grams/KBW/day Fluids 16-20 cc/KBW = 2.5-3 oz/lb body weight = more or less 20 oz/day c. Vitamins vitamins A,C, and D are recommended for both bottle feed and breastfeed babies during the entire first year of life.

G. 1.

2.

3.

NUTRIENTS Protein

HUMAN MILK 8%

COWS MILK 20%

69

Fats Carbohydrates Sodium Potassium Calcium Phosphorus Chloride

50% 42% 7 mEq/liter 14mEq/liter 12 mEq/liter 9 mEq/liter 12 mEq/liter

50% 30% 25% mEq 36 mEq/liter 61 mEq/liter 53 mEq/liter 34 mEq/liter

Table 14. Comparison Between Human Milk and Cows Milk c. Difference between human milk and cows milk Human milk contains less protein. Cows milk has more proteins but the newborns kidneys become overwhelmed with the higher protein content of the cows milk that is why cows milk need to be diluted. The main protein in human milk is lactalbumin; the main protein in cows milk is casein. Since the curd tension in milk is related to the amount of casein, the curd in cows milk is therefore larger, tougher and more difficult to digest (that is why bottlefed babies have frequent constipation). Heating reduces the curd, that is why cows milk must be sterilized or pasteurized so newborns can digest it. Human milk and cows milk have similar fat content; but, linoleic acid, which is necessary for growth and skin integrity, is three times higher in human milk than in cows milk. Besides, human milk has larger fat globules. Human milk contains more carbohydrates. Moreover, lactose in human milk appears to be the most easily digestible of all the sugars; it also improves calcium absorption and aids in nitrogen retention. Cows milk ha more minerals but, again, newborns kidneys become overwhelmed with high mineral content of cows milk that is why it has to be diluted first. Similarities between human milk and cows milk: Both of the m should be given by demand feeding Both bottlefed and breastfed babies should be burped at least twice during a feeding midway and after the feeding Both have the same energy value = 20 cal/ounce Both are deficient in iron

d. 4.

Common health problems a. Constipation more common among bottlefed infants. Management: Add more fluids or carbohydrates/sugar. If due to an unusually tight anal sphincter, dilate twice or trice a day by means of a gloved little finger b. c. Loose stools careful history should be taken; management depends on cause Colic paroxysmal abdominal pain common in infants below 3 months of age Causes: Overfeeding Gas distention Too much carbohydrates Tense and unsure mother Management:
70

d. e. f. g.

Feed by self-demand. It is the best schedule because it meets the individual needs of the newborn Tell mother to burp the infant at least during a feeding Fed baby in upright position May need to change formula, as per doctors order Reduce sugar content of formula Spitting due to poorly developed cardiac sphincter; more common among bottlefed infants. will disappear when coordination with swallowing is achieved and digestion improves. Management: Feed in upright position because gravity will aid in gastric emptying. Position on right side after feeding Bubble/burp more frequently Skin iritation maybe due either to poor hygiene or irritation from urine, feces and some laundry products. Management: Expose to air most important Careful washing and rinsing away of irritating soap from the skin Starch bath, if a case of miliaria (prickly heat) Occasional cross eyes normal in many babies because the eye muscle of coordination have not yet fully developed; will disappear spontaneously Seborrheic dermatitis/cradle cap involves the sebaceous glands; due to poor hygiene. Management: apply mineral oil or vaseline on the scalp at night before giving shampoo in the morning.

5.

Clothing the newborn rule of thumb: if the mother feels warm, keep the baby cool; if the mother feels cold, keep the baby warm. Sleep patterns baby sleep 16-20 hours a day

6.

RISK NEWBORNS Premature babies born before the 38th week of gestation Terminologies 1. Small-for-gestational-age (SGA) birth weight is less than expected for the specific gestational age. E.g., a baby born on the 38th week of gestation who weighs 5 pounds 2. Appropriate-for-gestational-age (AGA) birth weight expected for the specific gestational age. E.g., a baby born on the 34th week of gestation who weighs 5 pounds. 3. Large-for-gestational-age (LGA) birth weight more than expected for the specific gestational age. E.g., a baby born on the 36th week of gestation who weighs 8 pounds. Characteristics 1. Have underdeveloped subcutaneous tissues and less fat to act as insulation. Are thinskinned. This is the reason why rapid drying and warming inside incubators are important. a. Temperature 92 deg F 94 Deg F (33.3-34.4 deg C) b. Humidity 55-56% c. Frequent positioning on the right side will favor closure of the increased pressure on the left ventricle 2. Are poikilotherma (easily take on the temperature of the environment).temperature stabilized a lower rate: 35 Degrees 36 Degrees C. take the axillary, not the rectal, temperature becrying will mean increased energy expenditure. (Important: A special
71

I. A.

B.

consideration in the care of premature babies is conservation of energy for growth and development). 3. 4. Physiologic weight loss is exaggerated. general activity is more feeble and weak: they often assume frog-like position; extremities have less muscle tone (scarf sign elbow passes the midline of the body; square window wrist wrist at a 90 degrees angle). CNS centers for respiration are under-developed, which results in the irregular breathing with short periods of apnea. Oxygen administered should never be more than 40% because it can lead to retrolental fibroplasia (an overgrowth of retinal blood vessels causing blindness). Nutritional requirements are high in order to maintain rapid growth appropriate for the developmental stage. Birth weight, kidney and GIT functioning should be considered in determining nutritional requirements of the preemies. a. Method of feeding basically by NGT. Rationale: Prematures often have ineffective sucking which is not coordinated with swallowing and, therefore, may aspirate Minimal handling is necessary in order to conserve energy Procedure: Determine the distance to which the NGT is to be inserted by measuring from the earlobe to the nose to the distal end of the sternum. Mummify (restrain) the baby as the NGT is being inserted Check location after NGT has been inserted: ** Submerge tip of the NGT in a glass of water; if bubbles appear, it is inside the lungs ** Inject 5 cc of air, then auscultate. If no sound is heard as air is injected, it means that the NGT is not in the stomach but in the lungs ** Aspirate contents; if acids are aspirated, the NGT is in the stomach Determine amount of residual milk or undigested milk and subtract the same amount from the next feeding because this means that the baby is not able to digest all the milk that is given to him. Be sure to put back the residual milk since it contains acids and the baby can develop metabolic alkalosis if not given back to the baby. Keep the NGT always closed to avoid abdominal distention Fill syringe with formula before opening NGT; let formula flow by gravity Feed with sterile water after the formula in order to prevent clogging the NGT.

5.

6.

c.

Special Problems 1. Hyperbilirubinemia because of the immaturity of the liver, kernicterus (staining of brain damage or even death) appears to occur at a lower bilirubin level. Management: phototherapy photooxidation by the use of artificial blue light in order to convert bilirubin into an excretable form. Nursing responsibilities in phototherapy care: a. Expose all areas of the body to light by turning the infant every 2 hours b. Cover eyes and genitalia c. Give plenty of fluids to prevent dehydration d. Check the loose stools and increase body temperature

72

2.

Infection preemies are more susceptible because of the general immaturity of the immune system. All newborns receive IgG globulins (antibodies) from their mothers, but this is a time-related occurrence; it takes place during the last 2 weeks of pregnancy. Since the preemie would have been born by then, he is not able to receive the necessary protection normally obtained by full-term babies. Anemia exaggeration of the physiologic anemia of full-term newborns. All newborns manifest a gradual drop in hemoglobin levels for the first 6-12 weeks of life because the bone marrow stops producing RBCs in response to the elevated oxygenation in extrauterine respiration. The problem with preemies is that they have less iron stores (because transfer of iron stores from the mother to the baby also occurs during the last 2 weeks of pregnancy) and smaller RBC mass (since cord was cut immediately after delivery). Respiratory Distress Syndrome/Hyaline Membrane Disease the disease specific for premature babies

3.

4.

DECREASE PULMONARY SURFACTANT increased surface tension alveolar walls will not separate lack of expansion of affected alveoli decreased alveolar ventilation inadequate exchange of oxygen and carbon dioxide HYPOXIA increased capillary permeability which causes effusion from the pulmonary capillaries into the alveoli and terminal bronchioles HYALINE-LIKE MEMBRANE found in the alveoli and bronchioles composed mainly of fibrin ATELECTASIS.

Figure 20. Diagrammatic Presentation of RDS a. b. Pathophysiology The main problem is decreased pulmonary surfactants, substances responsible for maintaining expansion of alveolar walls after initial respiration The lack of expansion of affected alveoli decreases alveolar ventilation This results in inadequate exchange of oxygen and carbon dioxide, leading to hypoxia. Hypoxia increases capillary permeability, causing effusion from the pulmonary capillaries into the alveoli and terminal bronchioles Hyalin-like membrane forms around the alveoli and bronchioles, causing further hypoxia Atelectasis, the chief lesion of RDS, thus occurs. Signs and symptoms: Expiratory granting major symptom Increased respiratory rate Flaring alae nasi Cyanosis; retractions; rales Respiratory acidosis Blood values Low pH level (normal = 7.35-7.45) Low pCO2 level (normal = 40-60 mm Hg) High pCO2 level (normal = 35-45) Management: Monitor vital signs, arterial blood gases, skin color, muscle tone Proper positioning; NPO; IV; NGT cares
73

c.

 II. A.

Oxygen; high humidity; warmth; CPAP Suction PRN Prevent complications Sodium bicarbonate for acidosis

Postpartum/Postmature Babies born after the 42nd week of gestation Classic signs old man facies; evidence intrauterine weight loss, dehydration and chronic hypoxia 1. Long and thin 2. Cracked skin which is loose, wrinkled and stained greenish-yellow, with no vernix nor lanugo Long nails; firm skull Wide-eyed alertness of a one month old baby

3. 4. B.

Management: 1. Monitor vital signs 2. IV, as ordered

C. III. A.

Outlook: reasonable Tracheoesophageal fistula Definition: 1. Esophageal atresia failure of the esophagus to form a continuous passage from the pharynx to the stomach 2. Tracheoesophageal fistula abnormal sinus connection between the esophagus and the trachea Types See Figure 21 1. Type I/A upper and lower segments of the esophagus are blind; no connection to the trachea 2. Type II/B upper end of esophagus opens into the trachea; blind lower segment 3. Type III/C upper end is blind; lower end connect into the trachea. Most common type (85%) 4. Type IV/D both upper and lower ends of the esophagus open into the trachea by a fistula 5. Type V/E H type; no esophageal atresia but with fistula; rare type 6. Type VI/F stenosis occurs 2/3 of the way down the esophagus. Obstruction may be partial or complete. Clinical manifestations 1. Excessive amounts of secretions outstanding symptoms which occurs soon after birth: a. Constant drooling b. Large amount of secretions from the nose 7. Intermittent cyanosis due to aspiration from the blind upper pouch 3. Abdominal distention air from trachea passes through the fistula into the stomach 4. When fed, infant responds violently after first or second swallow: a. Cough and chokes b. Fluid returns through the nose and mouth c. Infant struggles d. 5. Inability to pass catheter through the nose or mouth into the stomach
74

B.

C.

D.

Diagnostic evaluation: 1. Maternal history of polyhydramnios helpful clue 2. Flat plate X-ray of abdomen and chest reveals presence of gas in the Stomach and chest 3. X-ray with radiopaque catheter; radiopaque contrast medium never used because of aspiration. Preoperative nursing care 1. Position newborn with the head and chest elevated 20-30 degrees to prevent reflux of gastric juices into the tracheobronchial tree 2. Regular suctioning 3. Put in incubator with high humidity to aid in liquefying secretions and thick mucus 4. Administer oxygen PRN 5. Assist in bougie treatment (elongation of proximal pouch using a mercury weighted dilator or firm catheters inserted briefly each day) 6. Give antibiotics as ordered to prevent or treat associated pneumonitis 7. Monitor IV or hyperalimentation 8. Observe closely for: a. Vital signs; respiratory behavior b. Amount of secretions c. Sbdominal distention d. Skin color Surgery: 1. Primary repair esophageal anastomosis and division of fistula 2. Gastronomy and cervical esophagostomy temporarily until infant gains weight. Staging (repeated operations separated by periods of time, waiting for growth) is the accepted philosopy of treatment. Postoperative care 1. Observe for signs of stricture at the anastomosis site; atelectasis; pneumonia 2. Maintain patent airway: a. Suction PRN mark catheter to determine how far it can be inserted without disturbing anastomosis site. b. Change position frequently and stimulate baby to cry but void hyperextension of the neck to prevent tension on the suture line c. Continued used of incubator 3. Maintain adequate nutrition oral feedings started 6-14 days postoperative a. Low residue diet to keep stools soft b. Feed slowly in upright position to allow time for swallowing 4. Oral hygiene to prevent bacterial growth 5. Allow infant to suck on a pacifier to meet psychological and physiological and physiologic needs. 6. Encourage parental participation to promote strong parental-infant bonding Chalasia A. Pathophysiology: On the 3rd to the 10th day of life, the cardiac sphincter muscles fail to function, causing it to be relaxed and constantly patent. B. Characteristics: Unknown causes; self-limiting disappears spontaneously within 3 months Signs and symptoms: 1. Prolonged, repeated non-projectile vomiting which is more pronounced when patient is lying flat on his back
75

E.

F.

G.

IV.

C.

2. 3. 4. D.

Often hungry after each vomiting episode Aspiration may occur Pressure on abdomen causes reflux of stomach contents into the esophagus

Management: 1. Thickened feeding (formula + cereals) because they are less easily vomited 2. Put on upright position for 30 minutes after every feeding

V.

Imperforate anus A. Unknown etiology arrest in embyologic development at 8 weeks of intrauterine life B. Types see Figurre 22 C. Signs and symptoms 1. No anal opening 2. Temporal colostomy if poor surgical risk (very young baby; malnourished; high agenetic or atretic type 3. Surgery: a. Anoplasty b. Abdominoperineal pull-through 4. Postoperative care: a. Expose perinium to air by putting infant on supine with legs suspended straight up or on prone position b. Check bowel sounds frequently c. NGT for gastric decompression d. Change position from side to side to decrease tension on suture line e. Oral feedings resumed 1-2 days postop when peristalsis has resumed (fluids are retained; stools/flatus passed) Spina bifida congenital problem in which there is a defective closure of the spinal column. A. Classification: 1. Occulta L5 and S1 are usually affected, with no protrusion of spinal contents. Skin over the defect may reveal a dimple, a small fatty mass or a tuft of hair. 2. Cystyca a. Meningocoele b. Myelominingocoele congenital failure of the arches of one or more vertebrae to unite at the center of the back, so that the bony wall surrounding the spinal canal at that place is missing. There is external protrusion through a transparent sac, containing spinal fluid, meninges, spinal cord and/or nerve roots. It is the most severe of the spinal deformities. B. 1. Associated clinical problems depends on the location, all body parts below the lesion are affected Motor function a. Feet may be deformed b. Joints of ankles, knees or hips may be immobile c. Variable degrees of weakness in the lower extremities d. Spontaneous and induced movements are decreased or absent. Sensory function: a. Sensations usually absent below the level of the defect b. Ulceration of the skin are common Impaired function of the autonomic nervous system: a. Skin is dry and cool b. Sweating ability is impaired Urinary and bowel problems: a. Inefficient bladder causes UTI b. Stasis of urine c. Possible renal destruction
76

VI.

2.

3.

4.

d. 5.

Fecal incontinence or retention due to poor innervation of the anal sphincter and bowel musculature

Hydrocephalus occurs 65% of children; usually develops within the first 6 weeks of life. Preoperative management/conservative treatment: Careful handling to avoid rupture, pressure, irritation or leakage from the protruding mass by putting child on prone position, with the hips abducted (see Figure 23) Meticulous skin hygiene to prevent irritation sterile donut ring over the lesion Watch for signs of increased intracranial pressure a. Anterior fontanelle for tenseness, fullness and bulging b. Shrill, high-pitched cry c. Measure head circumference daily for any significant increase d. Vomiting irritability e. Increasing BP, decreasing PR and RR and widening pulse pressure Passive range of Motion (ROM) exercise to impaired lower extremities

C. 1. 2. 3.

4. D.

Surgical correction 1. Early excision of the sac if it is small and then primary closure is done 2. If base of the defect is too large for primary closure, conservative treatment is carried out first while waiting for epithelization to take place and then closure is done at a later time. E. 1. 2. 3. 4. F. 1. 2. 3. Postoperative care Keep on prone position Monitor urine output bladder injury is a high possibility in operations involving the spinal column Measure head circumference daily Monitor movements of lower extremities Complications Meningitis Severe neurologic deficits hydrocephalus a. Types: Noncommunicating blockage within the ventricles which prevents CSF from entering the subarachnoid space Communicating obstruction of the subarachnoid cistern at the base of the brain and/or within the subarachnoid space b. Management 1.5-2.0 grams Mannitol 20%/KBW over 10-15 minutes since Mannitol is a diuretic, an indwelling catheter should be inserted for accurate recording of intaake and output ventriculo-peritoneal/ventriculo-atrial shunt to bring the CSF to an area from where it can be excreted from the body. After the procedure, the child should be positioned on the side where the shunt is to prevent sudden decrease in the intracranial pressuer

THE INFANT
77

I. II. III. IV. V.

Definition: The child from 0 to 12 months of age Psychosexual stage (Freud): Oral Psychosocial stage (Erickson): Trust vs. Mistrust Cognitive stage (Piaget): Sensory motor = 0 to 2 years play A. Purposes: 1. To practice motor skills 2. To gain coordination 3. To relate to objects and people B. Type: Solitary they love to play with their own bodies C. Age-appropriate toys: 1. Mobiles 5. Teething rings 2. Rattles 6. Textured balls 3. Musical box 7. Large, soft cuddly toys 4. Squeeze toys Greatest fear: stranger anxiety after 6 months of age Growth and development A. Definitions 1. Growth an increase in physical size of the whole body or any of its parts and can be measured by inches or centimeters and in pounds or kilograms 2. Development progressive increase in skill and capacity of function B. 1. 2. 3. General principles Children are competent they are well endowed with the qualities and abilities needed to ensure their survival and promote their development Children resemble one another the physical and behavioral characteristics of each age and the changes that occur with increasing age are similar from child to child. Each child is unique the differences from child to child are due to a combination of: a. Heredity and constitutional make-up b. Racial and nationl characteristics c. Sex d. environment Growth and develop are directional a. Cephalocaudal growth is more advanced at the near the head and gradually progresses downward to the neck, the trunk and extremities b. Proximo-distal growth proceeds outward from th central axis of the body toward the periphery c. General to specific e.g., from crying at birth to complete sentences at preschool age d. Simple to complex- e.g., from walking at 12 months of age to pedaling the trike at 3 years of age Asynchronous growth the whole body does not grow at once; different regions and subsystems develop at different rates and times. Discontinuity of growth rate there are only two periods of very rapid growth: the fetal infancy period and adolescence. Development is timely the notion of readiness or maturation states that learning would come quickly and effortlessly once the child is ready. (That is why the most common reason for failure in toilet training is that the child is not yet ready to be trained) New skills tend to predominate the current developmental issue becomes a preoccupation for the child. The many aspects of development (personal-social, fine motor-adaptive, gross motor and language) are interrelated. They act upon and react with one another extensively and inseparably.
78

VI. VII.

4.

5. 6. 7.

8. 9.

C.

Developmental screening by means of standardized tools, e.g., the Metro Manila Developmental screening Test (MMDST). It is a screening instrument for children aged 0 to 6 years to detect developmental delays early, thereby preventing further delays. (see Figure 24).

D. 1. 2.

3.

4.

5.

6.

7.

8.

9. 10.

11.

Specific behavior Newborn when on prone, avoids suffocation by turning his head from side to side One month a. Lift head intermittently when on prone b. Momentarily visual fixation on human faces and objects Two months a. Social smile b. responds to familiar voices by moving the whole body c. no head control yet; head lags when pulled to sitting (Implications: support head and neck when carrying the baby) d. sheds tears Three months a. Can raise head, but not chest, when on prone b. Head in bobbing motion; some head control when pulled to sit c. Babbies and coos d. 180 degrees visual arc Four months a. Can raise head and chest when on prone b. When in supine, head maintained in the midline, arms and legs are symmetrical and hands brought together in the midline c. May have bald occiput d. Grasp objects within reach and brings to mouth (Implication: diaper pins, clips, etc., should be kept out of reach) e. Head control when pulled to sit, no lag; no more bobbing, head steady when upright f. Sustains part of own weight when helped to standing position g. Laugh aloud Five months a. Rolls over (implication: raise side rails of cribs to prevent accidental falls) b. Raking grasp Six months a. Doubles birth weight b. Eruption of first tooth (usually lower central incisor) c. Sits with minimal support d. Can be pulled from sitting to standing position Seven months a. Plays with feet b. Says dad or mama but nonspecific c. Pivots (creeps) when on prone (Implication: keep rails on stair secured) d. Thumb-finger grasp Eight months: sits alone steadily without support for an indefinite period Nine months a. Can hold bottle with good hand-mouth coordination b. Crawls c. Understands simple gestures and requests (bye-bye or pat-a-cake) d. Takes some steps when held e. Neat pincer grasp Ten months a. Pulls self to stand
79

12.

13.

b. Responds to own name Eleven months a. Stands with assistance b. Attempts to walk with help Twelve months a. walks with help b. triples birth weight c. drinks from cup d. can say two words

RISK INFANTS I. Cleft Lip/Cleft Palate A. Incidence: Cleft lip, with or without cleft palate, is more frequent among males; but cleft palate alone is more frequent among females. B. Etiology: Primarily genetic therefore, there is a greater than average possibility of having other children with the same anomaly Types: Unilateral Bilateral Midline - rare Accompanying or associated problems Feeding the child is not able to maintain closed suction on the nipple Upper respiratory tract infection because the child breaths through his mouth. Ear infections because the pharyngeal opening of the Eustachian tube is in abnormal position. Speech defects Dental malformation Body image Definitive treatment surgery Surgery to close the cleft lip (cheiloplasty) is done as early as possible, using the Rule of 10. a. At 10 weeks old b. Weighing at least 10 pounds c. Having at least 10 grams hemoglobin Cleft palate surgery is not done very early (not earlier than 10-12 months because it can harm the tooth buds) nor too late (because the palate can become too rigid and the child might develop undesirable speech patterns) Velopharyngeal flap operation at 8-9 years of age to revise previous repair, correct nose deformities and reconstruct the nasopharynx for speech improvement. Preoperative Nursing Care Provide emotional support to parents parents have difficulty loving the infant and responding warmly to him; encourage verbalization of fears, guilt, anger, etc. Feeding the most immediate and apparent problem because the infant cannot maintain closed suction around the nipple nor use mouth movement adequately to pull on the nipple a. Use soft, regular, cross-cut nipple b. Burp more frequently because he swallows more air than usual c. Do not feed lying down should be in sitting or semi-sitting position to aid in successful swallowing and prevent choking
80

C. 1. 2. 3. D. 1. 2. 3. 4. 5. 6. E. 1.

2.

3.

F. 1. 2.

d. e. f.

Be patient he takes longer to feed Do not confine lying on back for long periods in order to prevent URTI and ear infections Give small amounts of water after feeding in order to rinse the mouth. Prevent dry, cracked lips especially since the baby breathes through the mouth

G. 1.

2.

Postop cheiloplasty Complication respiratory distress during the first 48 hours because of: a. Swelling of tongue, mouth and nostrils put downward pressure on the chin to increase air passage b. Increased respiratory secretions c. Difficulty adjusting to a smaller airway Nursing care a. Minimize reasons for crying because it adds to an already irritable and fussy child b. Put inside mist tent to liquefy respiratory secretions c. Can lie on his back d. Elbow restraints should be used at all times to prevent him from putting his hands or other objects into his mouth e. Logans bow is taped after surgery to protect the suture line from blows pressure and sucking (never let the child suck on the apparatus) Moisten the OS with sterile NSS OS is removed before feeding, then a new strip is applied after feeding and cleansing After feeding, the suture line is cleansed with a cotton-tipped applicator which has been dipped in one-half strength hydrogen peroxide in order to prevent crusts which cause uneven healing and infection, leaving ugly scars f. Feedings formula resumed around 3-4 weeks postop. A rubber-tipped medicine dropper which is placed to the side of the mouth away from the suture line is preferred to avoid tension on the suture line. Postop repair of cleft palate Complication: Hemorrhage Nursing care a. Position on abdomen to facilitate drainage of blood and mucus (REMEMBER: suction is never done) b. Use of mist tent is recommended c. Elbow restraints are also applied d. Sucking, blowing, talking, laughing, or putting objects into the mouth is not allowed e. feeding Paper cups are used, NEVER spoon, fork, knife, straw or glass Sterile water rinses are given after feeding Just like postop cheiloplasty, feedings are resumed 3-4 weeks after repair, when healing has already taken place. Give small, frequent feedings initially

H. 1. 2.

II.

Hypertrophic Pyloric stenosis A. Definition: congenital hypertrophy of the muscle of the pylorus in the stomach; the muscle becomes progressive thickened and elongated, with narrowing of the lumen B. 1. Sings and symptoms Projectile vomiting after 1 or 2 feedings during the 2nd-4th week of life a. Important points to consider: Vomiting is the initial symptom in upper GI tract obstruction (abdominal distention is the major symptom in lower GIT obstruction) Vomitus in UGIT problems is blood-tinged, not bile-streaked or vomiting of fecal material)
81

2. 3. 4. C. 1. 2. 3.

Vomiting is usually projectile if there is an obstruction (and non-projectile if without construction) b. Effects of vomiting Baby is always hungry afterwards Scanty, infrequent stools are observed Metabolic alkalosis and marked deficits of sodium and potassium Marked weight loss and dehydration 1-2 cm olive-shaped mass along the midepigastric plane to the right of the rectus muscle can be palpated gastric peristaltic waves are seen running across the abdomen from left to right after a feeding. On barium enema, the string sign can be seen Preoperative nursing care Monitor IV Accurate recording of intake and output Feed by gavage a. Thickened feeding at frequent intervals. Thickened feedings delay the emptying time of the stomach, thus increasing satiety and making vomiting less likely b. Feed slowly on semi-upright position c. Burp PRN because of poor peristalsis d. Observe rules regarding NGT feeding Treatment of choice: Fredet-Ramstedt separation of the hypertrophied muscles without incision of the mucosa Postop management recovery is rapid 1. NGT is inserted for gastric decompression drainage of fluid and gases prevents pressure on the suture lilne, thus preventing paralytic ileum (the most common complication after abdominal surgery)

D.

E.

2. 3.

Immediately postop, position child on his side with his back supported Resumption of feeding a. Consists of gradually increasing amounts of clear fluids that contain glucose and electrolytes. If well tolerated, diluter formula is given on the second day, with increasing concentration at each feeding until full formula can be given b. On the first few occasions that a dropper to ensure that the child obtains only small amount, thereby reducing stress at the pylorus. c. Feed on semi-upright position for 45-60 minutes and slightly to the right to increase gastric emptying time. Prognosis: recurrence is highly unlikely, i.e., it is very rare

F. III.

Intussusception A. Definition: Invagination or telescoping of a portion of the small intestine into a more distal segment of the intestine B. Incidence: More frequent in infants and very young children than in adults because children have hyperactive lower intestinal tract Signs and symptoms occur in an otherwise healthy child: Sudden onset of severe, spasmodic and explosive pain, causing the child to pull up his legs on to his abdomen and give out a loud, shrill cry. As pain subsides, child lies limp, pale and sweaty The pain occurs successively more intense and at shorter intervals.
82

C. 1. 2. 3.

4. 5. 6. 7. D. E. 1. 2. 3. 4. IV.

Vomiting is an associated symptom After a number of hours, the typical brown, bloody, mucoid stools (current jelly) can be observed On palpation, a sausage-shaped mass in the ascending or transverse colon can be felt. On barium X-ray, the staircase or coiled spring pattern can be seen. Complication: Gangrene of the bowel if not corrected immediately. Management: Barium enema NGT for gastric decompression Proper positioning Inform parents that recurrence is rare but limit childs activity after discharge

Hirschprungs Disease/Congenital Aganglionic Megacolon A. Definition: Congenital absence of parasympathetic ganglion nerve cells (which control defecation) usually in the rectosimoid area (therefore, a lower GIT obstruction) B. C. 1. 2. 3. 4. 5. Signs and symptoms shown in Figure 25 Preoperative management Good hygiene is important because the child is poorly nourished, apathetic and uncomfortable with distention and nausea Frequent, small feedings of low-residue diet Upright position for respiratory distress, supported with pillows or sandbags. Administration of antibiotics and stool softeners Frequent daily enemas to remove fecal matter a. Oil-retention enema Use funnel or syringe 75-150 ml mineral or olive oil at 100 degrees Fahrenheit (37.7degrees C) apply pressure over anus so as not to expel the solution b. Cleansing enema of isotonic solution (tap water is NEVER used when there is impaired water absorption because water intoxication, as evidence by muscular tremors and twitching, can result, and can even lead to convulsions, coma or death.

On supine, with pillows under the head an back. Buttocks are placed on a diaperlined bedpan. Dissolve 1 teaspoon salt in 1 quart of water (isotonic solution) Temperature of solution is 105 degrees F or 40.5 degrees C Enema can should not be more than 18 inches above hip level 10-12 French catheter is inserted 2-4 inches into the rectum no more than 300 ml should be given at a time

D.

Treatment of choice surgery: Swenson pull-through. If the infant is a poor surgical risk, a temporary colostomy in the distal portion where normal ganglia are found is done. Delay in meconium passage
83

NO NERVE CELLS

Obstinate constipation

Intermittent progressive Abdominal distention

Large fecal masses

Foul odor of Breath & stools Thin abdominal wall; Nausea prominent superficial veins

Abdominal pain, Fever, vomiting

Impaired absorption Of water & nutrients

Malnutrition lethargy & anemia Infrequent, spontaneous ribbon-like stools

Respiratory embarassment

Figure 25. Hirschprungs Disease V. Hernia A. Types 1. Diaphragmatic hernia failure of development of the posterolateral portion of the diaphragm resulting in the persistence of the pleuroperitoneal canal (Foramen of Bochladek). Abdominal organs (usually the stomach and the intestines) protrude into the chest cavity, usually on the left side, displacing the heart to the right of the chest and the lung collapsed. a. Signs and symptoms Presenting sign cyanosis and severe respiratory distress immediately after birth. Abdomen is scaphoid (not dome-shaped) Breath sounds are diminished or absent; bowel sounds are heard in the chest cavity. Intracostal and subcostal retractions are observed. b. Management Elevate head to improve breathing NGT to prevent distention Correction of respiratory acidosis with buffering agents, e.g., sodium bicarbonate or THAM Immediate surgical repair 2. Hiatal hernia a protrusion of the stomach through the esophageal hiatus. a. Incidence: more frequent and more severe in males; no stablished familial pattern b. Signs and symptoms Forceful vomiting between 1 week and 1 month of age, eventually containing old blood, resulting in anemia, weight loss, dehydration and malnutrition.

c. d.

Complication: aspiration pneumonia Diagnosis: Barium X-ray

84

e. f.

g.

h. 3. a.

b.

c. d.

e. 4. a. b. c.

Management of choice Surgery: Gastropexy = hiatus is reduced and stomach is tacked in. Preoperative care Give thickened formula Food in upright position and let child stay upright for hour after feeding. Postoperative care Underwater chest drainage and basic respiratory therapy for several days NGT for gastric decompression Monitor IV, intake and output Oral feedings resumed few days after: Small, frequent feedings, with much patience because the child eats slow, is inconsistent, tires easily and sometimes even refuses food. Use soft, preemie nipple Finger foods for older children to encourage independence Prognosis: Recurrence is common Inguinal hernia protrusion of hernial sac through the abdominal wall, the inguinal opening or into the scrotum. Incidence Maybe present at birth or appear at a later age More common in males and more often on the right, although maybe bilateral Signs and symptoms When infant cries or strains at stools, or when an older child coughs, stands or strains, the mass appears in the groin Silk-glove sensation (diagnostic of inguinal hernia in a perpendicular direction to the long axis of the canal allows the examiner to appreciate the peritoneal lining or hernial sac infant is fretful and anorexic; pain, difficulty in defecating and local pressure are sometimes felt infants are at risk of incarceration (= intestine becomes trapped in the sac), causing strangulation of the bowel, gangrene, rupture, even death Treatment of choice surgery: Herniorrhaphy. There is less risk of complications when elective, rather than emergency, surgery is done. Preoperative mangement Keep infant from straining Proper diet non-constipating Emotional support Postoperative care Diet as tolerated Infant can be as active as he desires when healing has taken place Umbilical hernia protrusion of the omentum or small intestine through a congenital weakness or opening of the umbilical ring. Incidence: Usually appears before 6 months of age and will generally vanish spontaneously by 1 year. Symptom: soft-tissue swelling covered by skin and may look like a finger protruding from the umbilicus when the infant cries, strains or coughs. Management Normally, is easily reduced by manipulation but may sometimes strangulate Surgery I, therefore, indicated if strangulation occurs

VI.

Diarrhea A. Causative agents 1. Bacteria Escherichia coli (most common), salmonella, dysentery 2. Viruses 3. Non-infectious a. Allergy to drugs/foods; parasites; change in formula
85

b. c.

Failure-to-thrive due to inadequate maternal-child relationship; eager to eat but frail; mother most likely had the same problem in childhood Irritable colon syndrome diarrhea starts and ends on its own accord.

B. 1. 2. 3. C. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Criteria for identification/diagnosis Change in the consistency (from formed to watery) of the stools most important Increase in the frequency of stooling Appearance of green-colored stools Signs of dehydration (the most common cause of fever in newborns and very young children) Increased pulse rate earliest sign Increased temperature and respiration Decreased BP Sunken fontanelles and eyeballs Poor skin turgor; dry skin Thirst; stingy saliva Dry mucous membranes Scanty urine Metabolic acidosis a. Lethargy an early sign b. Rapid, deep breathing Management Replacement of lost fluids and electrolytes by IV infusion or Oresol amount of fluids to be replaced is based on weight loss because 70 % of the body surface of children is made up of water and their body surface is greater than the weight sodium must not be replaced too rapidly because circulatory overload can occur: Distended neck veins Increased restlessness and irritability Increased PR and RR When air has entered the tubing, position child on his left side to prevent air from getting into his lungs If infusion is finished way ahead of the schedule, do not re-adjust refer to the doctor for a re-computation Sodium bicarbonate is given for acidosis Take temperature by axilla to avoid stimulation of peristalsis Meticulous skin care rinse soap carefully awy from the skin (soap is irritating to the skin) Administration of KCL as soon as normal urinary function has been established

D. 1. a. b.

c. d. 2. 3. 4. 5. VII.

Atopic Dermatitis/Infantile Eczema A. General considerations 1. Earliest manifestation of an allergic tendency in childhood; frontrunner of asthma 2. Hereditary predisposition is usual 3. Usually appears by the 4th month when solid foods start to be introduced and clears spontaneously by the 4th year. 4. Most often seen in well-nourished, well cared for, healthy infants B. 1. 2. Most common allergens Cows milk Wheat cereals
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3. 4. C. D. 1. 2. 3. 4. 5. 6.

Egg white egg yolk as source of iron is needed, not egg white; should not be given to infants below 1 year, especially if with family history of allergy. Kalamansi Vitamin C-rich fruits are highly allergenic fuits. Complication: Bacterial infection of lesions Signs and Symptoms Pruritus, erythema and edema, then papules and vesicles first evident on the cheeks, then spreading to the forehead, scalp and extremities Generalized lymphadonopathy; splenomegaly Low-grade fever Child is uncomfortable, fretful and irritable Increased eosinophil count (eosinophils engulf bacteria and contribute to body defense) Scarring may occur due to secondary infection. Over the years, skin thickened and darkens in color, called lichenification, the hallmark of chronic eczema. Management Accurate history to identify allergens that is why the first principle in the introduction of solid food is Introduce one new food at a time. Clove hitch restraint to prevent the child from scratching. Cleanse skin with mineral oil, plain water or NSS Burows solution wet compresses for bacteriostatic, antipruritic and drying effects

E. 1. 2. 3. 4. VIII.

Iron-deficiency Anemia A. General considerations 1. Most prevalent nutritional disorder in children because of overfeeding with milk (which is deficient in iron) 2. Most common hematologic disease in infancy and childhood because of rapid growth and development 3. Iron, when taken into the body, has only a 10% absorption rate a. High bulk in the diet, large amounts of milk and antacids will further decrease its absorption rate b. Is irritating to the gastric mucosa and therefore should be taken after meals. c. Vitamin C (fruits/juices) should be given together with iron for optimum absorption. B. 1. 2. 3. 4. C. 1. 2. 3. 4. 5. Causes Insufficient supply dietary deficiency; inadequate body stores Impaired absorption diarrhea; malabsorption syndrome Excessive demands growth requirements; chronic illness Blood loss hemorrhage; parasitic infestations Signs and symptoms Compensatory tachycardia Irritability; weakness; lack of interest in the surroundings; decreased exercise tolerance and anorexia Pallor; waxy, sallow appearance Dyspnea; increased RR; shortness of breath Edema; hepatomegaly

IX.

Bronchitis A. Definition: An acute respiratory infection involving the bronchioles wherein there is blockage of egress of air from the alveoli, resulting in overdistention of the lungs. B. Incidence: commonly affects robust infants with an allergic background. (Implication: repeated attacks necessitate closer follow-up because they may be associated with asthmatic allergic response).
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C. 1. 2. 3. D.

Cause basically VIRAL, therefore: Is self-limiting No drug choice Management is conservative/supportive Signs and symptoms severely ill for 48-72 hours, then gradually improves during the next 4-5 days. if severity lasts for more than 72 hours, there is probably a superimposed bacterial infection (usually bronchopneumonia) Restlessness earliest sign of respiratory distress in children Flaring alae nasi Rales; retractions Dyspnea; cyanosis Tachycardia With or without fever Respiratory acidosis Management mainly supportive Bed rest; NPO with IV to prevent aspiration due to respiratory distress Humidified oxygen to liquefy secretions Sodium bicarbonate for acidosis Epinephrine; bronchodilators; antibiotics if with superimposed bacterial complication Proper positioning: Prone the weight of the back will help compress the distended lungs Semi-fowlers with slight neck extension for fuller chest expansion and clearer airway

1. 2. 3. 4. 5. 6. 7. E. 1. 2. 3. 4. 5. a. b. X.

Sudden Infant Death syndrome (SIDS)/Crib Death A. Incidence 1. More frequent among premature who live overcrowded settings 2. Occurs while asleep 3. Peak age 2-3 months B. 1. 2. 3. C. D. E. 1. 2. 3. Theories of causation Viral infection affects the nerves controlling the vocal cords that spasm occludes the airway Some unknown neurologic problem interferes with respiration Is acute pancreatitis in children Definitive cause: unknown Management: support of the grieving parents Findings on autopsy Minor inflammation of the upper respiratory tract Petechiae over pleura Lung congestion

THE TODDLER

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I. II. III. IV.

Definition: The child from 1 to 3 years of age Psychosexual stage (Freud): Anal Psychosocial stage (Erickson): Autonomy vs. Shame Cognitive stage (Piaget): Stage I (Preconceptual stage) of the Preoperational Thought Period (2-4 years) = characterized by egocentricity expressed in relating everything to himself Play A. B. 1. 2. 3. Type: (Parallel) Age-appropriate toys Push-pull toys Building blocks Toys to ride on

V.

4.

Pounding pegs 5. Stuffed toys

VI. VII.

Greatest Fear (Separation anxiety) most acute at 2 2 years of age Behavioral traits A. Toddlers are (headstrong and negativistic) their favorite word is NO) they are slowly moving out of infancy and more closely defining their own independent activity B. They are naturally active, mobile and curious, which makes them vulnerable to accident so set limits and exert external control whenever necessary. (Remember: Love and consistency are the two most important concepts in child rearing). There is a distinct (decrease in appetite because of the slower growth rate) Pattern of weight gain First 6 months of life = 6-8 oz/week Second 6 months of life = 2-4 oz/week Second year of life = lb/month Characteristics Dawdling at meals Fetish with foods Appetite of three-year-old is more capricious than that of one-year-old They are rigid; repetitive, realistic and stereotyped in their behavior. When things are rearranged or are strange, when persons or places are unfamiliar, toddlers go into tantrums in order to control self and others. (Management of temper tantrums: Ignore the behavior or direct them to activities that they can master). Toddlers have very poor sense of time. Their time schedules revolve around their activities, not around the clock. Adults should talk to very young children at eye level the greater the disparity in size between an adult and a toddler can cause fear in the latter. Since all 20 deciduous teeth are out by 2 - 3 years, start teaching brushing of teeth at this time. Toddlerhood is the critical period (for toilet training)

C. 1. a. b. c. 2. a. b. c. D.

E.

F.

G.

H.

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Inferior Vena Cava

Inferior Vena Cava

Uterus During Contraction Uterus Between Contractions

Figure 16. Supine Hypotensive Syndrome

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PREGNANCY INDUCED HYPERTENSION

A. B. C. D. E.

DEFINITION CAUSE/ETIOLOGY INCIDENCE TYPES DIAGNOSIS/RISK ASSESSMENT 1. 2. Clinical History Taking MAP PE Roll Over Test Laboratory Test Use of Diagnostic Machine

3. 4. F. G.

PREVENTION MANAGEMENT 1. 2. 3. Control of B/P Prevent Convulsions Optimum Time & Mode of Delivery

PREECLAMPSIA

ECLAMPSIA Presence of Convulsion in a Woman with underlying preeclampsia

MILD

SEVERE

1. B/P = 30 mmHg 15 mmHg or

from the baseline

50 60 mmHg 30 mmHg or 160 mmHg or more 110 mmHg or more

140/90 & above if no baseline

(for client on bedrest X 2 readings 6 hrs apart)

2. Proteinuria 300 mg/24 hrs urine sample

4 5 gms/24 hrs
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or ( ++ ) by dipstick method

1,000 mg/random sample of urine 6 hrs apart ( ++++ )

3. EDEMA Pretibial fitting edema Digital/Periorbital edema weight gain of 1 lb/week

Massive generalized edema like pulmonary edema 5 lbs/week

4. OTHERS

- Persistence of vomiting - Irritability - IUGR - Suggesting of end -organ involvement - Cerebral or visual disturbance - Epigastric or RUQ abdominal pain

Oliguria < 400 500 cc/24 hrs MAP Mean Arterial Pressure Test

Defined as the Diastolic Pressure + 1/3 of pulse pressure Mathematical form: DBP + 1/3 (SBP DBP) = MAP

A MAP value in the second trimester (MAP 2) > 90 mmHg MAP value in the 3rd trimester (MAP 3) > 105 mmHg has resulted in an increased incidence of Preeclampsia and perinatal deaths. Example: B/P is 140/90 = 50 pulse rate 90 + Y3 of 50 is (16.6) = 106.6 MAP MAGNESIUM SULFATE

A.

Classification: (Anticonvulsant, CNS Depressant, Respiratory depressant) Toxicity : CNS absent DTRs CV Cardiac arrythmias Drowsiness Hypotension Hypothermia others: Respiratory paralysis

B.

C.

Nursing Considerations: 1. Contraindicated to patient with impaired renal function

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2. 3. 4.

5. 6. 7.

If to be given by IVTT it should be very slow for a period of 20 30 minutes in order to avoid RR and cardiac arrest. Antidote for MgSO4 toxicity is Ca Gluconate. This should be available at bedside, (given by bolus for a period of 5 minutes). Parameters for referral before giving Magnesium Sulfate: a. DTRs should be + + b. RR should be 16 breaths/minute c. UO should be at least 30 cc/hr Check other vital signs q 15 min when given by IVTT Use Magnesium sulfate parenteral with extreme caution to patient receiving digitalis preparation. If PIH patient is receiving MgSO4 of whatever route of administration within 24 hours before delivery, the neonate is watched for MgSO4 toxicity including neuromuscular & respiratory depession.

D.

DOSAGES AND ROUTE OF ADMINISTRATION Stock preparation: 500 mg/ml in 2 ml 250 mg/ml in 10 ml Given by: 1. Initial loading dose Like: Consist of one slow IVTT 1 deep IM on each buttocks

4 6 gm slow IVTT 5 gms deep IM on each buttocks Maintenance dose: 5 gram deep IM q 6 8 hrs

2.

FORMULA:

D=Q

or 1 2 gms/ hour (in soluset) Desired dose Stock on Hand Q amount to be given.

CLINICAL DISEASE PREECLAMPSIA

Management principles

CONTROL HYPERTENSION

PREVENT CONVULTION

OPTIMUM TIME AND MODE OF DELIVERY

DRUG OPTIONS - Hydralazine - Methyllodopa - Beta blockers - Ca channel Blockers

DRUG OPTIONS GOVERNING FACORS MgSO4 Diazepam Diazepam AOG Severity of disease Fetal & maternal status

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ABORTION Definition: Termination of pregnancy before it has reached the age of viability

Types/Classification: Induced 1. Therapeutic 2. Criminal/Illegal

1. 2. 3. 4.

Spontaneous Threatened Inevitable Missed Habitual

Causes: -

Chromosomal defects Congenital anomalies Exposure to teratogens radiations

Clinical manifestations: Mild uterine cramping Vaginal spotting bleeding Intact or rupture of membranes Progression of cervical dilatation Complications: Hemorrhage & sepsis Nursing Care: 1. Griefing process 2. assessment for hemorrhage 3. pad count 4. prevention of infection Treatment/Management: 1st 12 wks or 1st trimester 1. Suction & Evacuation 2. D&C 2nd trimester 1. D&C 2. Hysterotomy 3. Saline injection 4. Prostaglandin Instillation 5. Oxytocin

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