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Maternity Nursing
I. Human Sexuality
a. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes and
emotions and preferences that is related to sexual self and eroticism
2. Sex is basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human
sexuality
15 – 44 y.o. – age of reproductivity CBQ
Stages of Pubic Hair Development (Tool Used: Tanner’s Scale/ Sexual Maturity Rating)
b. Labia Majora – large lips latin, longitudinal fold from perenium to pubis
symphysis
c. Labia Minora – aka Nymphae, soft and thin longitudinal fold created between
labia majora
• Clitoris – “key”, pea – shaped erectile tissue composed of sensitive
nerve endings; sight of sexual arousal in females
• Fourchet – tapers posteriorly of the labia majora. Site for episotomy
2. Internal
a. Vagina – female organ for ovulation, passageway of menstruation, ¾ inches
8 – 10 cm long containing rugae
o Rugae – permits considerable stretching withouit tearing
during delivery CBQ
b. Uterus – hollow muscular organ, varies in size, weight and shape, organ of
menstruation
Size : 1 x 2 x 3
Shape : pear shaped, pregnant - ovoid
Weight : Uterine involution CBQ
Non pregnant : 50 – 60 g
Preganant : 1000 g
4th stage of Labor : 1000 g
2nd week after of Delivery : 500 g
3rd weeks after delivery : 300 g
5 – 6 Weeks after delivery: 50 – 60 g
Three Parts of Uterus
• Fundus – upper cylindrical layer
• Corpus/ Body – upper triangular layer
• Cervix – lower cylindrical layer
Isthmus – lower uterine segment during pregnancy
Dx Exam: biopsy,laparoscopy
Tx: Lupron (luprolide) inhibits FSH & LH
Tx: Danazol (Danacrine) DOC
Inhibits ovulation
stop menstruation
b. Myometrium
o Power of labor
o Smooth muscles is considered to be LIVING LIGATURE
(muscles of delivery, capable of closing) of the body
o Largest portion of the uterus
c. Peremetrium
o Protects the entire uterus
c. Ovaries
• 2 female sex gland
• almond shape
• Fxn: Ovulation,production of 2 hormones( estrogen and progesterone)
d. Fallopian Tube
• 2 – 3 inches long that serves as a passageway of the sperm from the
uterus to the ampulla or the passageway of the mature ovum or fertilized
ovum from the ampulla to the uterus
• 4 significant segments
o Infundibulum – most distal part, trumpet shape, has fimbrae
o Ampulla – outer 3rd or 2nd half, site of fertilization, common site for
ectopic preg.
o Isthmus – site for sterilization, site for BTL
o Interstitial – most dangerous site for ectopic pregnancy
1. External
• Penis
• The male organ of copulation and urination
• Contains of a body or shaft consisting of 3 cylindrical layers and erectile
tissues
o 2 corpora cavernosa
o 1 corpus spongiosum
• At the tip is the most sensitive area comparable to clitoris = glans penis
• Scrotum
• Pouch hanging below the pendulous penis, with medial septum deviding
into 2 sacs each containing testes
• Requires 2 degrees celcius for continuous spermatogenesis
• Cooling mechanism of testes
2. Internal
The Process of Spermatogenesis
Testes
(900 coiled seminiferous tubules)
↓
epididymis
(site of maturation of sperm 6 m)
↓
Vas Deferens
(conduit pathway of sperm)
↓
Seminal Vesicle
(secreted: fructose form of glucose, nutritative value
Prostaglandin: causes reverse contraction of uterus)
↓
Ejaculatory Duct
(conduit of semesn)
↓
Prostate Gland
(release alkaline substances)
↓
Cowpers Gland
(release alkaline substance)
↓
Urethra
Hypothalamus GNRH
↓
APG
↓
FSH – maturation of sperm
LH – testosterone production
Leydig Cells – releases testosterone
1. On the initial phase of menstruation, the estrogen level is ↓, this level stimulates
the hypothalamus to release GnRH/ FSHRF
2. GnRH/ FSHRF stimulates the anterior pituitary gland to release FSH
• FSH Function
o Stimulate ovaries to release estrogen
o Facilitate the growth of primary follicle to become
GRAAFIAN FOLLICE structure that secretes large amount of
estrogen that contain mature ovum
3. Proliferative Phase (↑estrogen)
Follicular Phase – responsible for the variation and irregularity of mense
Postmenstrual Period – after menstruation
Preovulatory Phase – happen before menstruation
4. 13th day of menstruation, estrogen level is PEAK while progesterone is ↓, these
stimulates the hypothalamus to release GnRH/ LHRF
5. GnRH/ LHRF stimulates the Anterior Pituitary Gland to release LH
• Functions of LH
o Stimulates the release of progesterone
o Hormone for ovulation
6. 14 day estrogen level is ↑ while progesterone level is ↑
th
• S/S
o Rupture of the graafian follicle - OVULATION
o Mittelschsmerz – slight abdominal pain lower right
quadrant
7. th
15 day, after ovulation day, graafian follicle starts to degenerate, estrogen level
↓, progesterone ↑, causing degeneration of the graafian follicle becoming yellowinsh
known as CORPUS LUTEUM – secretes large amount of progesterone
8. Secretory Phase
REFRACTORY PERIOD – only period present in male, wherein he cannot restimulated for
about 10 – 15 minutes
III. Blastocyst enlarging cell forming a cavity that later becomes the embryo covered by
thropoblast which later becomes the placenta and membrane
IV. Implantation 7 – 10 days after fertilization
• Thropoblast – covering of blastocyst that become placenta
• S/Sx of Implantation Slight pain, Slight Vaginal Spotting
• 3 Processes
o Apposition
o Adhesion
o Invasion
2. Embryonic Stage
Zygote – fertilization to 14 days
Embryo – 15th – 2 mos/ 8 weeks
Fetus – 2 mos to birth
c. Decidua – thickened endometrium, latin word for “falling off”
1. Basalis – located directly under the fetus where placenta developed
2. Caspularis – encapsulates the fetus
3. Vera – remaining portion of and endometrium
d. Chorionic Villi – 10 – 11 weeks
1. Chorionic Villi Sampling (CVS) – removal of tissue from the fetal postion of the
developing placenta
• For genetic screening
• Fetal limb defects, missing digits of toes
e. Cytothrophoblast – outer layer, LANGHAN’S LAYER, protect the fetus against syphilis
(24 weeks/ 6 months)
f. Synsitiotrophoblast – syncitial layer – responsible for hormone production
1. Amnion – inner most layer 2. Chorion
I. Umbilical cord (Funis) – whitish gray (50 – 60 cm)
• Short abruptio placenta, uterine inversion
• Long cord prolapse, cord coil
• 3 vessels (AVA) – Artery Vein Artery
• Wharton’s Jelly – protects the umbilical cord
II. Amniotic fluid bag of water clear color, musty/mousy odor
• With crystallized forming pattern, slightly alkaline
• 500- 1000 cc Normal
o Oligohydramnios – kidney malformation
o Hydramnios – GIT , TEF/ TEA
• Functions
o Cushion the fetus against sudden blow or trauma
o Maintains temperature
o Facilitate muscuskeletal development
o Prevents cord compression
o Helps in development process
• DRUGS
o Streptomycin – anti – TB – (quinine) damage to the 8th cranial nerve poor learning
and deafness/ ototoxic
o Tetracycline – stoning the tooth enamel, inhibits long bone growth
o Vitamin K – hemolysis, destruction of RBC, jaundice, hyperbilirubenemia
o Iodides – enlargement of thyroid and goiter
o Thalidomides – anti-emetics Amelia or Pocomelia absence of distal part of
extremities
o Steroids – cleft lip or palate and even abortion
o Lithium – congenital maformation
• ALCOHOL – LBW, fetal alcohol syndrome ( characterized by microcephaly)
• SMOKING – LBW
• CAFFEINE – LBW
• COCCAINE – LBW, abruptio placenta
• TORCH – group of infections that can cross the placenta or ascend through the birth canal
and adversely effect fetal growth
o Toxoplasmosis – cat lovers
o Others - Hepa AB, HIV, Syphillis
o Rubella – CHD,
Rubella Titer – N @ 1:10 or ↓ = immunity to rubella = notify doctor
Rubella vaccine after delivery for 3 mos. No pregnancy for 3 mos.
o Cytomegalo virus
o Herpes Simplex virus
Systemic Changes
1. Cardiovascular System
• ↑ blood volume 30 – 50%
• 1500 cc; additional 500 cc for multiple pregnancy
• ↑ plasma volume
• ↑ cardiac workload – easy fatigability/ slight ventricular hypertrophy
• Epistaxis due to hyperemia of nasal membrane
• Palpitation due to SNS stimulation
• Physiologic Anemia/ pseudoanemia in pregnacy
o Normal Value
Hct : 32 – 42%
Hgb: 10.5 – 14 g/dl
o Criteria
1st & 3rd Trimester : Hct > 33% Hgb > 11 g/dl
2nd Trimester : Hct > 32% Hgb > 10.5 g/dl
o Pathologic Anemia
Iron Defficiency Anemia is the most common hematologic disorder. It
affects 20% of pregnant women
Assesment reveals:
• Pallor
• Slowed capillary refill = Normal = 2 – 3 sec
• Concave fingernails (late sign of progressive anemia) – clubbing
= chronic tissue hypoxia
• constipation
Nursing care
• Nutritional instruction
o Source of iron
Kangkong
Liver = best source due to FERRIDIN Content
Red and lean meat
Green Leafy Vegetables
• Parenteral Iron (Imferon)
o Z tract IM
o incorrect causes hematoma
o best given 1 hour before meals (causes GI irritation)
o Maybe given 2 hours after meal (results to poor
absorption)
Given with orange juice to ↑ absorption
• Oral Iron Supplements (ferrous sulfate 0.3 g 3 x a day)
• Monitor for hemorrhage
Alert
• Iron from red meat is better absorbed iron from other sources
• Iron is better absorbed when taken with foods high in Vitamin C
such as orange juice
• Higher iron intake is recommended since circulating blood
volume is increased and heme is required from production of
RBCs
• Edema
o Impeded venous return due to the gravid uterus
o Nursing Intervention
Elevate legs above the hips level
• Varicosities
o Wear support stockings
o Elevate legs
• Vulvar Varicosities
o D/t pressure of gravid uterus
o Side –lying with pillow under the hips
o Modified knee – chest position
• Thrombophlebitis
o Presence of thrombus in inflamed blood vessels
o + Homan’s Sign – pain on the calf upon dorsiflexion
o Medical Management
Anticoagulant/ HEPARIN
• Does not cross the placental barrier
• Monitor APTT
• Antidote: PROTAMINE SULFATE
• No aspirin
• Milk Leg/ Plagmasia Alba Dolens
o Shiny white legs due to stretching of skin & hyperfibrinogenemia
o Nursing intervention
Check dorsalis pedis pulse (compare both)
Never massage
Assess for Homan’s sign only once
2. Respiratory System
• Shortness of Breath d/t gravid uterus
• Nursing intervention: Side-lying – lateral expansion of the lungs
3. Gastrointestinal System
• Nausea and vomiting
• Morning Sickness
o Due to ↑ HCG levels
o Crackers 30 min before arising
o AM – Carb diet 30 mins
o PM – small frequent meal
• Constipation
o Due to PROGESTERONE = ↑ fluid reabsorption due to ↓ GIT motility
o Nursing intervention
• ↑ Fluid
• ↑ Fiber
• Exercise
• Flatulence
o Due to increased progesterone
o Avoid gas forming foods
• Heartburn (pyrosis)
o Reflux of stomach content into esophagus
o Nursing Intervention
• Small frequent meals
• Sips of milk
• Avoid fatty and spicy foods
• Proper body mechanics
o Waist Above – Acid
o Waist Below – Base
• Hemorrhoids
o Due to gravid uterus
o Hot sitz bath for comfort
• Ptyalism
o ↑ salivation
o Mouthwashes to relieve
4. Urinary System
• Normal = + 1 sugar due to Progesterone via BENEDICT’S TEST
• First Trimester - Frequency
• Second Trimester - normal
• Third Trimester - Frequency
5. Muscoloskeletal
• Calcium sources
o Milk - ↑ Ca ↑ P – 1 pint/ day or 3 – 4 servings/ day
o Cheese, Yogurt, Head of Fish, Sardines, Anchovies, Brocolli
• Lordosis
o Pride of Pregnacy
• Waddling Gait
o Awkward gait while walking due to relaxin
o Prone to accidental falls
A. Local Chnages
• Vagina
o Chadwick’s Sign – bluish discoloration
o Leukorrhea – whitish gray, moderate in amount, mousy odor
• Cervix
o Goodel’s Sign – change in consistency of uterus
o Operculum – mucus plug to seal bacteria/ progesterone
• Uterus
o Hegar’s Sign – change in consistency
Vagina Chadwick’s
Cervix Goodel’s
Uterus Hegar’s
Mycostatin
Contrimazole – Canisten
Gentian Violet
1. Abdominal Changes
• Striae Gravidarum
o Due to destruction of the subcutaneous tissue by the enlarge uterus
2. Skin Changes
• Melasma/ Chloasma
o White light brown pigmentation related to ↑ melanocytes
• Linea Nigra
o Brown pinkish line from symphysis pubis to umbilicus
3. Breast Changes
• Due to hormonal changes
• Change in color and size of nipple and areola
• Precolostrum – 6 weeks
• Colustrum – 3rd trimester
• Supine with pillow under the back
4. Ovaries – rest period, no ovulation
5. Signs and Symptoms of Pregnancy
Presumptive Probable Positive
S/sx felt and observed by the Signs observed by Undeniable signs confirmed
mother but does not confirm the members of the by the use of instrument
the diagnosis of pregnancy health care team
First Breast changes Goodel’s sign Ultrasound Evidence
trimester Urinary changes Chadwick’s sign
Fatigue Hegar’s sign
Amenorrhea Elevated BBT
Morning sickness Positive HCG
Enlarge uterus
Second Chloasma Ballotement
Trimester Linea Nigra Enlarge Abdomen etal Heart Tone
Increase Skin Pigmentation Braxton Hicks etal movement
Striae gravidarum Contraction etal outline
Quickening etal parts palpable
First Trimester
• No tangible s/sx
• Feeling of surprise
• Ambivalence
• Denial of pregnancy maladaptation
• Developmental Task: Accept biological facts of pregnancy
• Health Teaching: Body changes of pregnancy and Nutrition
Second Trimester
• Tangible s/sx
• Mother identifies fetus as separate entity due to quickening
• Fantasy
• Developmental Task: Accept growing fetus as a baby to nurture
• Health Teaching: Growth and development of fetus
Third Trimester
• Mother has personally identifies with the appearance of the baby
• Developmental Task: Prepare child birth and parenting the child
• Health Teaching: responsible parenthood, prepare baby’s layette, Lamaze Class
• Address Mother’s fear let she hear the FHT
Basic Consideration
1. Frequency of Visit
• 1 – 7th mos. once a month
• 8 – 9th mos. twice per month
• 10th month every week
2. Personal Data
• Home Based Mother’s Record/ HBMR determines high risk pregnancy
• Pseudocyesis false pregnancy appearance of presumptive & probable signs
• Comade Syndrome psycosomatic disorder, father experience what the mother
goes through
3. Diagnosis of Pregnancy
• Urine Exam HCG 40 – 100th day; peak 60 – 70th day
• ELISA beta subunits of HCG is detected as early as 7 – 10th day
5. Obstetrical Data
Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age
G2P0 G2 T0 P0 A1 L0
c. Important Estimates
1. Nagele’s Rule
• Use to determine expected date of delivery
• Jan – Mar +9 months +7 days
• Apr – Dec -3 months +7 days + 1 year
2. McDonald’s Rule
• Determines age of gestation in weeks
• Fundic Height x 7/8 = AOG in weeks
3. Bartholomew’s Rule
• Determines age of gestations
o 3 mos – above pubis symphysis
o 5 mos – level of umbilicus
o 9 mos – below xiphoid process
o 10 mos – level of 8th mos
4. Haases Rule
• Determines the length of fetus in cm.
• 1st half square each month
• 2nd half month x 5
d. Tetanus Immunization
5. Physical Examinations
a. Danger Signs of Pregnancy
Chills & Fever
Cerebral Disturbances
Abdominal Pain epigastric pain auro of impending convulsion
Boardlike Abdomen Abruptio placenta
Blurred Vission pre eclampsia
Bleeding abortion/ ectopic pregnancy – 1st trimester
H Mole/ Incompetent Cervix – 2nd trimester
Placental Anomalies – 3rd Trimester
BP ↑
Swelling
Scotoma – spots in the eye
Sudden gush of fluid – PROM – premature rupture of membrane
6. Pelvic Examination
Pelvic examination or IE – empty bladder, precaution
1st visit – Chadwicks, Goodle’s sign, etc.
Position : dorsal recumbent, lithotomy
Pap smear – done 1st visit
Cytological exam – determine presence of cancer cells.
Result :
o Class I – normal
o Class II A – cytology without evidence of malignancy
B – suggestive of inflammation
o Class III – cytology suggestive of malignancy
o Class IV – cytology suggestive og malignancy
o Class V – conclusive for malignancy
Most common cancer report organ : cervical cancer
Most common site for pap smear – external OS of cervix (squamocolumnar tissue)
Common site of cervical cancer. maternal – speculum (open)
Stages of cervical cancer
o 0 – carcinoma in situ
o 1 – Ca strictly confined to cervix
o 2 – from cervix extends to the vagina
o 3 – pelvic metastasis
o 4 – affectation to bladder & rectum
7. Leopolds Maneuver
Purpose: Done to determine the attitude, fetal presentation, lie, presenting part, degree of
descent an estimate of the size, and no. of fetuses
Procedure
1. 1st maneuver
o place patient in supine position with knees slightly flexed. Put towel under head and
right hip. With both hands palpate uppe4r abdomen and fundus. Assess size, shape,
movement and firmness of the part
o determine the presenting parts:
2. 2nd maneuver
o with both hands moving down, identify the back of the fetus where the ball of the
stethoscope is placed to determine FHT.
o PR of mother : uterine soufflé – MHR
o fundic soufflé – FHR
3. 3rd maneuver
o using the right hand, grasp the symphysis pubis part using the thumb and fingers.
o Assess whether the presenting part is engaged in the pelvis.
o Alert! If the head is engaged it will not be movable
4. 4th maneuver
o the examiner changes the position by facing the patient’s feet. With two hands, assess
the descent of the presenting part by locating the cephalic prominence or brow.
o When the brow is on the same side as the back, the head is extended. When the brow
is on the same side as the small parts, the head 8is flexed and vertex presenting.
Attitude – relationship of fetus to one another.
Full Flexion – when the chin touches the chest
b. Nonstress Test
o to determine the response of the fetal heart rate to the stress to activity.
o Indications – pregnancies at risk for
o placental insufficiency
o Postmaturity
• pregnancy induced hypertension (PIH), diabetes
• warning signs noted during DFMC
• maternal history of smoking, inadequate nutrition
o Procedure :
• Done within 30mins wherein the mother is in semifowlers position; external
monitor is applied to document fetal activity; mother activates the “mark button”
on the electronic monitor when she feels fetal movement. Attach external
noninvasive fetal monitors
• tocotransducer over fundus to detect uterine contractions and fetal movements
(FMs)
• ultrasound transducer over abdominal site where most distinct fetal heart
sounds are detected
• monitor until at least 2 FMs are detected in 20mins.
o if no FM after 40mins provide women with a light snack or gently stimulate fetus through
abdomen
o If no FM after 1hr further testing may be indicated, such as a CST
o Result :
• Noncreative Nonstress Not Good
• Reactive Response is Real Good
o Interpretation of results
• Reactive result – real good
baseline FHR between traction beteen 120 and 160 beats per min.
at least two accelerations of the FHR of at least 15 beats per min., lasting
at least 15secs in a 10 to 20 min period as a result of FM
good variability – normal irregularity of cardiac rhythm representing a
balanced interaction between the parasympathetic (↓ FHR) and
sympathetic (↑ FHR) nervous system; noted as an uneven line on the
rhythm strip
result indicates a healthy fetus with an intact nervous system
o Nonreactive result – not good
stated criteria for a reative result are not met
could be indicative of a compromised fetus requires further evaluation
with another NST, biophysical profile, (BPP) or contraction stress test
(CST)
9. Health Teachings
o do nutritional assessment
o daily food intake
o determine habit
hypertension (PIH)
Calcium-Phosphorous
Essential for Calcium ↑ of Calcium ↑ should reflect
• Growth and development of • 1200mg/day representing an • Dairy products, milk, yogurt,
fetal skeleton and tooth ↑ of 50% above pre ice cream, cheese, egg yolk
buds pregnancy daily requirement • Whole grain, tofu
• Maintenance of • 1600mg/day is recommended • Green leafy vegetables
mineralization of maternal for adolescent • Canned salmon & sardines
bones and teeth • 10mcg/day of vitamin D is with bones
• Current research is required since it enhances • Ca fortified foods such as
demonstrating an absorption of both calcium orange juice
association between and phosphorous • Vitamin D sources fortified
adequate calcium intake milk, margarine, egg yolk,
and the prevention of butter, liver, seafood
pregnancy induced
hypertension
Iron
Essential for Non Pregnat:15mg/day
• Expansion of blood volume & Pregnant : 30mg/day Iron ↑ should reflect
RBC formation - representing a doubling • liver, red meat, fish, poultry,
• Establishment of fetal iron of the prepregnant daily eggs
stores for first few months of life requirement • enriched, whole grain cereals
• Begin supplementation at & breads
30mg/day in second • dark green leafy vegetables,
trimester, since diet alone is legumes
unable to meet pregnancy • nuts, dries fruits
requirement • vitamin C sources: citrus
• 60 – 120mg/day along with fruits & juices, strawberries,
copper and zinc cantaloupe, tomatoes, green
supplementation for women peppers, broccoli or
who have low Hgb values cabbage, potatoes
prior to pregnancy or who • iron form food sources is
have iron deficiency anemia more readily absorbed when
• 70mg/day of vitamin C which served with foods high in vit
enhances iron absortion C
o Inadequate iron intake
results in maternal effects
anemia, depletion of iron
stores, ↓ energy and
appetite, cardiac stress
especially during labor &
birth
o fetal effects ↓ availability
of oxygen thereby
affecting fetal growth
• iron deficiency anemia is the
most common nutritional
disorder of pregnancy
Zinc
Essential for 15 g/day representing an ↑ of Zinc ↑ should reflect
• the formation of enzymes 3mg/day over prepregnant daily • liver, meats
• maybe be important in the requirement • shell fish
prevention of congenital • ↑grains, legumes, nuts
malformation of the fetus
Folic acids, folacin, folate
Essential for 400mcg/day representing an ↑ ↑ should reflect
• Formation of RBC & of more than 2x the daily Liver. Kidney, lean beek, veal
prevention of anemia prepregnant requirement • Dark, green leafy vegetables,
• DNA synthesis & cell broccoli, asparagus,
formation; may play a role in 300mcg/day supplement for artichokes, legumes
the prevention of neural women with low folate levels or Whole grains, preanuts
tube defects (spina bifida), dietary deficiency
abortion, abruption placenta
Additional requirements
Minerals ↑ requirements of pregnancy
• Iodine 175mcg/day can easily be met with a
• Magnesium 320mg/day balanced diet that meets the
• selenium 65mcg/day requirement for calories and
includes food sources high in
the other nutrients needed
during pregnancy
Vitamins
E 10mg/day
Thiamine 1.5mg/day
Riboflavin 1.6mg/day
Pyridoxine (B6) 2.2mg/day
B12 2.2mcg/day
Niacin 17mg/day
b. Sexual Activity
• Principles of sex in Pregnancy
o Should be done in moderation
o Should be done in a private place
o That the mother should be placed in a comfortable position
o It must be avoided 6 weeks prior to EDD
o Avoid blowing of air during cunnilingus
• Contraindication in sex:
o vaginal spotting – 1st tri
o incompetent cervix – 2nd tri
o placenta previa, abruption placenta – 3rd tri
o pre-term labor R: prostaglandin – oxytocin – contraction
o PROM – infection
• Changes in sexual appetite during pregnancy:
o 1st tri - ↓
o 2nd tri - ↑
o 3rd tri - ↓
c. Exercise
• strengthen muscle to be used during the delivery process
• Walking – best form of exercise
• Squatting – strengthen perineum & ↑circulation to the perineum (raise the buttocks before head
to prevent postural hypotension)
• Tailor sitting – same purpose with squatting
• Kegel exercise – strengthen pubococcygeal muscle
• Abdominal exercise – muscle of the abdomen ( done as if blowing a candle)
• Shoulder circling exercise – strengthen muscle of the chest
• Pelvic rocking exercise or pelvic tilt – relieve low back pain & maintain good posture (arching
back for 3 sec)
• Principles of exercise
o must be done in moderation
o must be individualized
d. Childbirth Preparation
• Overall goal: To prepare patents physically & psychologically while promoting wellness
behavior that can be used by parents & family thus, helping them achieved a satisfying &
enjoying childbirth experiences.
• Psychological
o Bradley Method – Dr. Robert Bradley – discoverer
advocated active participation of husband during labor & delivery to serve as
coach, based on “imitation of nature”
Features:
• darkened room
• quiet & calm environment
• relaxation technique
• close eyes
o Grantly Dick Read Method
fear can lead to tension while tension can lead to pain. (break cycle by
removing the fear-by abdominal breathing exercises & relaxation technique)
• Psychosexual
o Kitzinger Method – Dr. Shiella Kitzinger
pregnancy, labor & birth & the care of the newborn is an important turning point
in a woman’s life cycle. “flowing with contractions rather than struggle with
contractions”
• Psychoprophylaxis
o Lamaze – Dr. Ferdinand Lamaze
Prevention of pain thru mind & requires discipline, conditioning & concentration
with the husband’s help.
Features:
•conscious relaxation
• cleansing breathe – inhaling thru nose & exhaling thru mouth
• effleurage – gentle circular massage
• over abdomen to relieve pain
• imaging
• Different methods of delivery
o birthing chain – semi-fowlers – mother
o bathing bed – dorsal recumbent
o squatting – position relieve on back pain & maintain good posture
o Leboyer’s method
features :
• darkly lighted room
• quiet & calm environment
• room temp.
• soft music
o Birth under water
• Duration of Labor
o Primipara – 14 hrs but not more than 120 hrs
o Multipara – 8 hrs but not more than 14 hrs
• Nursing Interventions in Each Stage of Labor
o First Stage: onset of contractions to full dilatation & effacement of the cervix
o stage of effacement & dilatation
Latent Phase:
• Assessment:
o Dilatations 0-3 cm
o Frequency 5-10 mins
o Duration 20-40 mins
o Intensity mild
o Mother is excited, apprehensive but can communicate
• Nursing Care:
o Encourage walking : shortens 1st stage of labor
o Encourage to void q 2-3 hrs : full bladder inhibits uterine
contraction
o breathing (chest breathing technique)
Active Phase:
• Assessment:
o Dilatations 4-8 cm
o Frequency q 3-5 mins lasting for 30-60 secs
o Duration 30-60 secs
o Intensity moderate
• Nursing Care:
o M – edications – have meds ready
o A – ssessment include: v/s, cervical dilatation & effacement,
fetal monitor, etc
o D – ry lips – oral care (ointment), dry linens
o Breathing – abdominal breathing
Transitional Phase:
• Assessment:
o Dilatations 8-10cm
o Frequency q 2-3 mins contractions
o Duration 45-90 sec
o Intensity strong
o Two Types
Longitudinal Lie (Parallel)/ Vertical
• Cephalic – when the fetus is completely flexed
o Vertex
o Face
o Brow
o Chin
• Breech
o Complete breech – thigh rest on
abdomen while legs rest on thigh
o Incomplete breech
Frank – thigh resting on abdomen
while legs extend to the head
Footling
Kneeling
Transverse Lie (Perpendicular)/Horizontal lie
• Position – relationship of the fetal presenting part
to specific quadrant of the mother’s pelvis.
o ROA/LOA
left occipito anterior
o Breech – sacro
place the stethoscope above the
umbilicus
o Chin – mentum
o Shoulder – acromnio dorso
Monitoring the contractions & fetal heart tone
• spread the finger lightly over the fundus to monitor the contraction
• Increment/Cresendro - beginning of contraction until it increases
• Apex/Acne – height of contraction
• Decrement/Decresendro – from height of contraction until it decreases
• Duration – beginning of contraction to the end of the same contraction
• Interval – from end of contraction to the beginning of the next
contraction
• Frequency – from the beginning of 1 contraction to the beginning of
next contraction
• Intensity – strength of contraction
• if contract – blood vessel constricts; the fetus will get the oxygen on the
placenta reserve which is capable of giving oxygen to the fetus up to
1min.
• Duration of placenta to the fetus should not exceed 1min.
• Significance During active phase, if ↑ to 1min should notify the AMD
• ↑ BP; ↓ FHT : best time to get BO & FHT just after a contraction
Episiotomy
Prevent laceration
Widen the vaginal canal
Shortens the 2nd stage of labor
2 types
o MEDIAN
Less bleeding
Less pain
Easy repair
Possible urethroanal fistula major disadvantage
o MEDIOLATERAL
More bleeding
More pain
Hard to repair and slow healing
Ironing the Perenium prevent laceration
PELVIS
3 Parts
o Inlet – AP diameter narrow, transverse wider
o Cavity – between inner and outer
o Outlet – AP diameter wider, transverse narrow
LINEA TERMINALES
Nursing Care
COMPLICATIONS OF LABOR
Dystocia
Difficult labor related to mechanical factor
Primary cause is Uterine Inertia
Uterine Inertia
Sluggishness of contraction
Types
o Primary/ Hypertonic
Intense contraction resulting to ineffective pushing
Management : Sedation
o Secondary/ Hypotonic
Slow, irregular contraction resulting to ineffective pushing
Management : Oxytocin Augmentation
Prolonged Labor
> 20 H for primi
> 14 H for multi
proper pushing should be encourage if inappropriate:
o may cause fetal distress
o caput succedaneum
o cephalhematoma
o maternal exhaustion
monitor contractions and FHT
Precipitate Labor
labor less than 3 hours
causes excessive laceration leading to profuse bleeding hypovolemic shock
s/sx of hypovolemic shock HYPO TACHY TACHY
o HYPOtension
o TACHYpnea
o TACHYcardia
o Cold clammy skin
o Management
Modified trendelenburg
Fast Drip IV
Inversion of Uterus
Situation in which uterus is turn inside out due to:
o Short cord
o Hurrying of placental delivery
o Ineffective fundal push
Cause profuse bleeding hypovolemic
Hysterectomy
Uterine Rupture
Rupture of uterus
Caused by
o Previous classical CS
o Very large baby
o Improper use of oxytocin
S/sx
o Sudden pain
o Profuse bleeding
Prepare fore TAHBSO
Physiologic Retraction Ring boundary between upper and lower uterine segment
Bandl’sPathologic Ring suprapubic depression sign of uterine rupture
Trial Labor
Fetal head measurement = measurement of pelvis
6 hours labor allowance given to mother
monitor FHT and contractions
Preterm Labor
labor after 20 weeks and before 37 weeks
Triad signs
o Premature conditions every 10 minuets
o Effacement of 60 – 80%
o Dilatation of 2 – 3 cm
Home Management
o CBR
o Avoid Sex
o Empty bladder
o Drink 3 – 4 Glasses of H2O
Full bladder inhibit contraction
Hospital Management
o If Cervix Close (Criteria: cervix is closed if it is 2 – 3 cm dilated only)
2 – 3 cm dilated, pregnancy can be saved
Tocolytic Therapy
• Yutupar (Ritodine HCl)
o Side effect maternal BP < 90/60
o Check Impt. Presence of crackles
• Brethine (terbutaline) Bricanyl
o DOC
o Side effect: sustained tachycardia
o Antidote: propanolol/ inderal
• Mg SO4
o If cervix is dilated ( > 4cm)
Give steroid dexamethasone
• Promote surfactant maturation
• Immediately cut the cord after delivery to prevent jaundice/
hyperbilirubinemia
POSTPARTAL PERIOD
Genital Tract
o Fundus
goes down 1 finger breadth a day
10th day – non palpable behind the symphysis pubis
Subinvolution
• delayed healing of uterus containing quarters or clots of blood
• may lead to puerperal sepsis
• Management : D&C
o After Pains
After birth pains
Multiparous breastfeeding – most common to develop
Position = prone
Cold compress
Mefenamic acid
o Lochia
Components
• Blood
• Deciduas
• WBC
• Microorg
3 types
• Rubra – 1 – 3 days, musty, moderate amount
• Serosa – 4 – 10th day, pink or brown
• Alba – 10 – 21th day, crème white, ↓ amount
Urinary Tract
o Urinary Frequency – due to urinary retention with overflow
o Dysuria
Damage to trigone of the bladder
Urine collection for culture and sensitivity
Stimulate navel to urinate
Palpate bladder
Running water listening
Pull pubic hair - stimulate cremasteric reflex
Colon
o Constipation
Due to NPO
Bearing down may cause pain
Perenium
o Pain relieved by sim’s position
o Cold compress 1st 24 hours if there is pain at episioraphy followed by warm
EMOTIONAL SUPPORT
1. Taking phase
• 1st 3 days
• dependent phase
• passive, can’t make decision
• tells about childbirth experience
• focus on: Hygiene
2. Taking Hold
• 4 – 7th day
• dependent to independent phase
• active, decides actively
• focus: care of newborn
• health teaching : Family planning
3. Letting Go
• Interdependent phase
• Redefines goals, new roles as parents
• May extend till the child grows
Postpartal Complications
Hemorrhage
bleeding within 24 hours postpartum
1. Uterine Atony
boggy fundus
profuse bleeding
interventions
o massage the uterus
o cold compress
o modified trendelenburg
o fast drip IV
o breastfeeding – to release oxytocin
2. Laceration
well contracted uterus with profuse bleeding
assess perenium for laceration
degrees of laceration
o 1st degree – vaginal skin and mucus membrane
3. Hematoma
bluish discoloration of subQ tissues of vagina or perenium
candidates
o delivery of very large babies
o pudendal block
o excessive manipulation due to excessive IE
intervention
o cold compress 10 – 20 min then allow 30 minutes rest period for 24 h
Infection
Sources
o Endogenous – from normal flora of the body
o Exogenous – from the health care team
Most common – Anaerobic Streptococci
Management
o Supportive care
o ↑ Fluid intake
o TSB if there is fever/ cold compress + paracetamol may also be given
o Analgesics
Given on time to achieve maximum effect
o Culture and sensitivity
Perenial Infection
Same s/ sx with infection
2 – 3 stitches are dislodges
with purulent drainage
Tx – resuturing
Endometritis
Inflammation of the endometrium
Gen s/sx of infection + abdominal tenderness
Management
o High fowler’s – facilitates drainage & localize infection
o Administer oxytocin
Guiding Principles
1. determine your own beliefs first
2. never advise a permanent method of family planning
3. informed concent
4. the method is an individual decision
Social Methods
Coitus Interuptus
withdrawal
least effective method
Coitus Reservatus
sex w/o ejaculation
Coitus interfemora
between femor
Calendar Method
14 days before menstrual cycle – ovulation day (regular)
- 4, + 4 days – unsafe period
Origoknause Formula ( irregular menstrual cycle)
get the longest and shortest cycle
subtract 18 to shortest
11 to the longest
the difference is the unsafe period
PILLS
combined oral contraceptives preventovulation by inhibiting the anterior pituitary gland
roduction of FSH and LH which are essential for he maturation and rupture of a follicle.
Estrogen inhibit FSH which is responsible in the mturation of ovum. Progesterone inhibit LH
which is responsible for ovulation.
contains estrogen that inhibits FSH and progesterone that inhibit LH
99.9% effective
21 day feel on the 5th day of mense start taking
28 day – 1st day of mense
if forgotten, take 2 tablets the following day
adverse effect : breakthrough bleeding
if mother wants to get pregnant
o wait 3 monts
o another 3 months if unsuucessful before consulting gyne
contraindications
o chain smoking
o Hypertension
o DM
o Extreme obesity
o Thrombophlebitis
Side effects (ressembles Hypertension)/ Immediate Discontinuation
o Abdominal paon
o Chest pain
o Headache
o Eye problem
o Severe leg cramp
Alerts on oral contraceptives :
o In case a Mother who is taking an oral contraceptive for almost a long time and plans
to have a baby, she would wait for at least 3mos before attempting to conceive to
provide time for estrogen and progesterone levels to return to normal. If after 6months
the mother did not get pregnant, consult AMD.
o If a new oral contraceptive is prescribed, the mother should continue taking the
previously prescribed contraceptive and begin taking the new one on the first day of
the next menses.
o Discontinue oral contraceptive if there is signs of severe headache as this are an
indication of hypertension associated with increase incidence of CVA and
subarachnoid hemorrhage.
If forget to drink pill for 1 day, take 2 pills the next day. If forget to drink pills for 2days,
o
stop the pill and wait for the next mens.
Adverse reaction : breakthrough bleeding
DMPA – Depoprovera
Contains progesterone
Depomedroxy progesterone Acetate
IM q 3 months – never massage the site may decrease effectiveness
NORPLANT
6 match stick like capsules/ rod
contain progesterone
sub Q planted
good for 5 years
Mechanical Device
IUD
prevent implantation
alters mobility of sperm and ovum
99.7% effective
best inserted after delivery and during menstruation
Common complication – EXCESSIVE MENSTRUAL FLOW
Common problem – EXPULSION OF THE DEVICE
No protection against STD
Side effects include
o Uterine infection
o Uterine perforation
o Ectopic pregnacy
Major indication for the use is PARITY
HT: monthly check up and regular pap smear
CONDOM
Made up of latex
Put in erected penis or lubricated vagina
Prevents sperm to enter the uterus
FEMALE CONDOM – higher protection than that of male
DIAPRAGHM
Dome shaped rubberied material inserted at the cervix to prevent sperm getting inside the
uterus
Reusable
HT : Proper hygiene
o Check for holes
o Must be refitted in case of weight gain of 15 lbs - - board question
o Kept in place for about 6-8 Hours – Board question
Contraindicated to
o Frequent UTI
CERVICAL CAP
More durable than the diaphram
Could stay on place for more than 24 hours
No need to apply spermicides
Contraindicated to – abnormal papsmear
CHEMICAL
SPERMICIDES
FOAMS – most effective
Jellies
Creams
These may cause toxic shock syndrome
SURGICAL METHOD
Bilateral tubal Ligation
o @ isthmus
o 20% probability of reversal
Vasectomy
o Vas deferens is cut
o More than 30 x or 0 sperm count or 2 x negative sperm count before it could be
consider safe sex
General management
CBR
Avoid sex
Prepare ultrasound – determine the sac integrity
Assess bleeding and approximation
Assess hypovolemia
Save discharge for histopathology
o Determine whether the product of labor has been expelled
2. Blighted ovum
3. germ plasm defect
o Natures way of expelling defective babies
o Classifications :
1. Threatened
• pregnancy is jeopardized by bleeding and cramping but the cervix is
closed and can be saved.
2. Inevitable
• moderate bleeding, cramping, tissue protrudes from the cervix and the
cervix is open.
o Types :
1. Complete
• all products of conception are expelled.
• Mgt : emotional support
2. Incomplete
• placenta and membranes retained.
• Mgt : D&C
HABITUAL
o 3 or more consecutive pregnancies result in abortion usually related to incompetent
cervix.
o Management (suture of cervix)
1. McDonald procedure
• Temporary circlage
• Side effect – infection
• May have NSD
2. Shirodkar
• CS delivery
MISSED
o fetus dies; product of conception remain in uterus 4 weeks or longer
o signs of pregnancy cease
1. (-) pregnancy test
2. Dark brown
3. Scanty bleeding
o Mgt : induction of labor/ vacuum extraction
INDUCED
o Therapeutic abortion principle of 2 fold effect
1. Done when mother has class 4 heart disease
Ectopic Pregnancy
• occurs when gestation is location outside the uterine cavity
• Common site : Ampulla or Tubal
• Dangerous site: Interstitial
Unruptured Ruptured
• Missed period • sudden, sharp severe unilateral
• Abdominal pain within 3- 5wks of pain, knife like
missed period (maybe generalized • shoulder pain (indicative of
• Nursing Care :
o vital signs
o administer IV fluids
o monitor for vaginal bleeding
o monitor I&O
o prepare for culdocentesis to determine
o hemoperitoneum
• Mgt : non-surgical Methotrexate
Placenta Previa
• it occurs when the placenta is improperly implanted in the lower uterine segment, sometime
covering the cervical os.
• Assessment
o Outstanding sign : frank, bright red, painless bleeding
o enlargement (usually has not occurred)
o fetal distress
o abnormal presentation
• Nursing care :
o Initial mgt : NPO candidate for CS
o Bedrest
o prepare to induce labor if cervix is ripe
o administer IV
o No IE, No Sex, No enema – complication : Sudden fetal blood loss
o prepare Mother for double set –up –DR is converted to OR
Abruptio Placenta
• it is the premature separation of the placenta from the implantation site.
• It usually occurs after the twentieth week of pregnancy
• Cause:
o Cocaine user
o Severe PIH
o Accident
• Assessment:
o Outstanding sign : dark red & painful bleeding
o concealed hemorrhage (retroplacental)
o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
o rigid boardlike abdomen
o severe abdominal pain
o dropping coagulation factor (a potential for DIC)
HYPERTENSIVE DISORDER
Diabetes Mellitus
o cause by absent & lack of Insulin
o Action of Insulin is to facilitate transfer of glucose into the cell
o Dx test : 50gm 1hr Glucose Tolerance Test
o ↑ 130 – hyperglycemia
o ↓ 70 – hypoglycemia
o 80-120 – euglycemia
o if > 130mg/dl, the Mother needs to undergo a 3hr GTT
o Maternal Effects :
o hypoglycemia during the 1st trimester development of the brain sinisipsip ng fetus
yung glucose ng nanay.
o Hyperglycemia during the 2nd & 3rd trimester
HPL effect Mgt : give insulin. OHA are teratogenic.
1st trimester - ↓ insulin, 2nd trimester - ↑ insulin, post partum – drop suddenly
Frequent infections eg. Moniliasis
Polyhydramnios
Dystocia
o Fetal Effects :
o hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd
trimester thru facilitated diffusion
o Macrosomia/LGA .4000gms
o IUGR due to prolonged DM
o Preterm birth promote still birth
o Newborn Effects :
o Hyperinsulinism and Hypoglycemia
40mg/dl
Normal : 45-55mg/dl
Borderline : 40mg/dl
Sx : ↑ pitched shrill cry, tremors, jitteriness
Dx test : heel stick test to check glucose levels
o Hypocalcemia
< 7mg/dl
Calcemic tetany
Tx : Ca gluconate
Heart Disease
o Classification :
o I – no limitation
o II – Slight limitation, ordinary activity causes fatigue
good prognosis can deliver vaginally
Mgt : sleep of 10hrs/day, rest 30mins after meals
o III – moderate limitation, less than ordinary activity causes discomfort
poor prognosis. Good for vaginal delivery
Mgt : early hospitalization by 7-8mos
o IV – marked limitation of physical activity for even at rest there is fatigue
poor prognosis. Good for vaginal delivery only with regional anesthesia.
Low forceps delivery when unable to push & to shorten the stage of labor
Mgt :
• therapeutic abortion, high semi- fowlers position, left side lying, no
valsalva maneuver - may trigger cardiac arrest, heparin therapy
required, antibiotic therapy for prevention of sub acute bacterial
endocarditis
INTRAPARTAL COMPLICATIONS
Cesarean Delivery
• Indications
a. multiple gestation
b. diabetes
c. active herpes II
d. severe toxemia
e. placental previa
f. abruption placenta
g. prolapse of the cord
h. cephalo pelvic disproportion and primary indication
i. breech presentation
j. transverse lie
• procedure :
o classical – vertical incision
o low segment – “bikini”, for aesthetic purposes. Can have vaginal birth after c/s
• Cystic fibrosis
• Celiac
• PKU
• Galactosemia
X- Linked Recessive
• Hemophilia
• Duchenne’s muscular dystrophy
• Color blindness
X – Linked Dominant
• Rickette’s