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Obstetrical Nursing

Monday, August 3, 2020 8:11 AM

Each pregnancy must be:


• Planned
○ Timing
▪ 2−3 children per couple
○ Spacing
▪ 3−5 years
• Wanted
○ Undergo prenatal checkup
○ Based on EINC:
▪ Minimum of 4 check ups
▪ <4
▪ month
▪ 6th
▪ 8th
• Monitored 9th
• Supported

Anatomy and physiology of Male RS


• Fully erect • Vasectomy
penis ○ Still use condom within 2months
○ 4−5 inches ○ Sperm free semen
• Urethra ○ 2 consecutive 0 sperm counts to confirm efficacy
○ Passageway for urine and semen
• Prepuce
○ Foreskin
○ Can produce a smegma
• Scrotum
○ Left scrotal sac is slightly lower
○ Rugate
○ Contains sperm
▪ Heat sensitive
○ Lower than 1 degree Fahrenheit compared to body temp
• Testes
○ Sex gland (gonad)
○ Responsible for spermatogenesis
○ Produce testosterone
• Epididymis
○ Sperm grows and matures here
○ Takes 64 days to mature
• Vas deferens
○ Collects sperm to SV
○ Seminal fluid enables sperm to move through VD
▪ 5% epididymis
▪ 30% seminal vesicle
▪ 5% cowper's gland
▪ 60% Prostate gland
• Seminal vesicle
○ Lubricates sperm 30%
○ Pre cum causes pregnancy becos sperm escapes ejaculatory duct
▪ Produces alkaline to withstand acid
• Cowper's gland
• Prostate gland

Normal sperm analysis


• 3−5mLƒ ejaculation
• 20m to 150mƒmL
• Minimum required sperm count ƒmL: t least 10mL
• ƒejaculation: 400mL
• 72 hrs life span (3−5 days)
• pH: 7−8 (vaginal canal: 4−5)
• Motility 50%
• Viability 50%
• Morphology 30%
Anatomy and physiology of Female RS
• Fourchette
○ Labia majora and minora meet
• Orifice
○ Urethral opening
▪ 2−3 inches
○ Vaginal orifice
• Vaginal canal
○ 3−4 inches
○ Rugate
○ pH: 4−5
○ Doderlein bacilli
▪ Produces lactic acid
○ Birth canal
○ Organ of copulation
○ Passageway for menstrual flow
• Uterus
○ Hallow muscular organ • Non pregnant: Forward: urinary bladder
○ Anteflexion (abnormal) Backward: rectum
○ Layer
▪ Perimetrium ○ Anteverted
□ outer • Pregnant:
▪ Myometrium ○ Retroverted
□ Middle ▪ 2nd trimester
□ Main muscle (origin of uterine contraction) ○ Retroflexion (abnormal)
▪ Endometrium
□ Inner
□ Area of implantation
○ Fundus
▪ Thickest layer
▪ Origin of uterine contraction
○ Corpus Chadwick's sign
○ Isthmus Bluish discoloration of vaginal mucosa
○ Cervix Goodell's sign
▪ Internal OS Softening of cervix
□ Effacement Non pregnant (tip of the nose)
◆ Means of % Early pregnancy (earlobe)
▪ Cervical Late pregnancy ( lips)
Hegar's signs Primi: 12−26h average of 14
canal
Softening of isthmus CE−CD
▪ External canal
□ Dilation Multipara: 6−8h average of 7
CD then CE or simultaneous
◆ Means of cm
○ 2 segments
▪ Upper
□ Myometrium: Uterine contraction (strongest)
□ Endometrium: area of implantation and placental devt
◆ Until endo only
◆ If involves myometrium
Q Placenta is permanently attached, hence, cant separate (placenta accreta)
◗ hysterectomy
□ Flat palm down with fingers in upper segment to feel contraction
▪ Lower
○ Ligaments that support the uterus
▪ Broad ligament
□ Keeps uterus and fallopian tube in place
▪ Round ligament
□ Upper support
▪ Cardinal ligament
□ Middle support
□ Stability of uterus
▪ Pelvic floor ligament
□ Lower support
• Ovaries
○ Female gonad
○ Produces estrogen and Penis > vagina
progesterone Glans penis > glans clitoris
• Fallopian tube Scrotum > labia
○ Known as oviduct Vas def > fallopian
○ 3−4 inches tube Testes > ovaries
○ 4 parts
▪ Infundibulum Testosterone > EƒP
□ Edge is fimbriae
▪ Ampulla
□ Outer
□ Widest part
▪ Isthmus
□ middle
▪ Interstitial
□ Innermost
□ Narrowest part
Egg lifespan: 1−2 days
○ Fx
as:
▪ Site of fertilization
▪ Transports fertilized egg to the endometrium
○ Are ciliated in lining
○ Hormones:
▪ Estrogen
□ Enlarges uterus
□ Encourages contraction
▪ Progesterone
□ Pregnancy
□ Prevents contraction
□ Provides nutrients
• Pelvis
○ Types:
▪ Gynecoid
□ True female
□ Well rounded
□ Support pregnancy
▪ Anthropoid
□ Obling−ish
□ Support pregnancy
▪ Android
□ True male
□ Heart shaped
▪ Platypelloid
□ Flat pelvis
○ False pelvis: supports growing uterus
○ True pelvis: supports birth canal
○ Ischial spine:
▪ Landmarks for stations
▪ 1 station = 1cm
▪ Start of engagement: 0 cm
▪ + engagement: negative ballottement (vice versa)
AP transverse O
inlet 11 13 12
cavity 12 12 12
outlet 13 11 12

○ Decent
○ Flexion
○ Internal Rotation
○ Extension
○ External Rotation
○ Expulsion

• Breast
○ Breast tissue
○ Arreola
▪ Lactiferous duct > Lactiferous sinuses > nipple opening
○ Acinar cells
○ Pituitary gland:
▪ APG: prolactin
□ Stimulates milk production
▪ PPG: oxytocin
○ Sucking nipples stimulates PPG to release oxytocin and contracts ampulla to excrete milk
○ Latching promotes high milk flow and minimizes nipple discomfort for the mother
○ Warm water without soap to clean nipples

Menstruation
• Discharge of blood coming from uterus
• Menstrual period:
○ Days that there is menstruation
○ 3−7 days
• Menstrual cycle:
○ Start of first day of period to first day of next period
○ 23−35 days
• Length of cycle determines day of ovulation
○ Could change any time
○ Cycle − 14 = day of ovulation
○ Minimum of 6 weeks in computation to determine if irregular or regular
• Fertile week
○ Should be regular
○ Ovulation − 5 then ovulation plus 3
• Day of ovulation
○ Compute 2 weeks before the mens
• If irregular
○ L − 11
○ S − 18
• Different structures that control menstrual cycle
○ Hypothalamus
▪ Produces gonadotropic releasing hormone
□ Follicle stimulating hormone releasing factor
□ Luteinizing hormone releasing factor
○ ABG
▪ FSH
□ Maturation of egg cells
▪ LH
○ Ovaries
▪ Estrogen 3 low E 13 low P
□ Converts follicle of ovary to graafian follicle
▪ Progesterone 13 high E 14 high P
□ Coverts GF to corpus luteum
□ Increased 02, h2O, glucose
○ Uterus
▪ Estrogen thickens endo and myo when there is low E
○ Placenta appears on 2nd month of pregnancy
○ CL extends lifespan within 2w to 2m
Pre menstrual syndrome
• Release of prostaglandin makes PMS painful
• Don'ts
○ Caffeine Foodƒbeverages
○ No salty food as it causes fluid
○ retention Smoking
• Do's
○ Exercise
○ Warm compress
Menopause
• Ceases of menstruation
• 45−50 yƒo • Bilateral tubal ligation
• Stops producing estrogen ○ Area is isthmus
• sƒs:
○ Hot flushes
○ Mood swings
○ Sagging of boobs
○ Dyspareunia
▪ Lubricant use
○ Decreased want in sex
○ Kidney stones
○ Prone to fracture
• Emphasize MMR
▪ Flat shoes ○ Mutual monogamous relationship
○ Osteoporosis
▪ Calcium supplement

Father determines gender of baby


• X − gynosperm
○ big head, small tail
○ Slow moving
○ Contains more alkaline
• Y − androsperm
○ small head, big tail
○ Fast moving

It takes 7−10 days for implantation to occur after fertilization


Decidua basalis + chorionic villi = placenta
Zygote > cleavage > morulla
Chorionic villi: produces human chorionic gonadotropin (HCG)
Normal HCG level: 50k to 400k (if > than, becomes more nauseous)

Fetal development
• Pre embryonic
○ First 2 weeks after fertilization
• Embryonic
○ 2 weeks to 2 months
• Fetal stage
○ 2 months to birth
○ Organogenesis
○ Self medication is not allowed
• Ammon
○ Inner
○ 2 structures:
▪ Funisƒ umbilical cord
▪ Amniotic sac
• Chorion
○ Outer
○ Placenta will arise

Funic souffle almost in sync with FHR


• Flow of fetal blood in umbilical cord
Umbilical cord
• is 50−55cm
• AVA
○ UA− deoxy
○ UV − oxy
○ Gelatinous substance around AVA: Wharton's jelly
▪ 50−55cm
▪ Cushion
▪ Sometimes, 1 artery is lost, therefore there is also 1 renal artery = 1 kidney
• Cx:
○ C prolapse
▪ Baby still inside but cord is exposed
▪ Don’t push back the cord as it causes infection
▪ Position by elevating pelvic area
□ Trendelenburg
□ Knee chest
□ Dorsal recumbent with pillow under buttocks
▪ Fetal distress
□ Check FHR (tachycardia)
□ Color of amniotic fluid (green)
□ Kick count (average of 10)
◆ <5 hypoactive fetus
◆ >15 hyperactive fetus
▪ Best delivered via CS
○ C
coil Cord coiled around the baby, duh
▪ Factors:

□ Long cord coil
□ Polyhydramnios
□ Gestational age baby
□ Double cord coil
▪ Clamp, clamp then cut the cord
○ C knot
▪ 2 types
□ Single
□ Double
▪ Low oxygen supply
▪ Affects the side of baby
▪ Poor brain devt
▪ Increases perinatal loss
□ Could die anytime
• Amniotic sac
○ Contains AF
▪ Min 500mL, Max 1.2k: ave 1k
▪ Oligohydramnios
▪ Polyhydramnios
▪ 99% water, 1% solid particles
□ Vernix
caseosa
□ Albumin
□ Bilirubin
□ Urea
➢ If high, fetus is producing good amount of surfactants that lubricates alveoli
□ Lecithin ➢ 2:1 for LS ratio
□ Sphingomyelin
▪ Green
□ Fetal distress
▪ Gra
y Infection

▪ Golden
□ Blood incompatibility
• Breech presented bb
○ Bottom first
○ Normal to have greenish AF
○ Could be caused by FD or pressure but one cant assess if it really is FD
• Non breech presented bb
○ If there is uteroplacental deficiency, anal sphincter relaxes, therefore causes meconium stain
○ Automatic sign of fetal distress

For emergency CS:


Left lateral
Face mask 5−8Lƒmin

Rh Incompatibility
• Inside the placenta, fetal blood is only found since maternal blood cant be mixed becos of placental barrier
• Rhesus factor as determinant
• Could be a problem if placenta is damaged
• Isoimmunization
○ Mother produces antibodies
○ Must be prevented
○ Coomb's test
▪ To determine if mother produced antibodies
▪ Direct: fetal blood
▪ Indirect: maternal blood
▪ Should have (−) result (not yet produced antibodies)
□ Give RhoGAM to prevent antibody production
• If not prevented, might cause hyperbilirubinemia
○ Phototherapy
▪ Turn from time to time
▪ Cover eyes and genital
▪ Increase feeding
2 sides of placenta
• Fetal side
○ Where cord is
○ Shiny and plain looking
• Maternal side
○ Dark and dirty looking
2 types of placental separation
• Schultz
○ Fetal side first
○ Center to periphery
• Duncan
○ Maternal side first
○ Periphery to center
○ Cx:
▪ Retained placental fragment
Pre natal check up
• Facility based check up
• Min reqt is health center
• Manned by competent and trained staff
• Main goal: decrease maternal morbidity and neonatal mortality rate
○ Demographic danger
▪ Age
□ <18, >35
◆ Pregnancy induced hypertension (young, primiƒ old, multipara)
◆ Normal: 2.5−4kgs
▪ Height
□ <5ft
□ Cephalopelvic disproportion dƒt small pelvis
◆ Determine by xray pelvimetry only by 3rd trimester, 2 weeks before EDC
▪ Weight
□ <90lbs, >150lbs
□ 24−30lbs normal weight gain during pregnancy
□ 1st tri: 1lbƒmonth (3)
□ 2nd tri and 3rd tri: 1lbƒwk (24)
□ 24−30
▪ Sudden weight gain
□ Check for edema on lower extremities
□ Attain BP
○ Hx of previous pregnancy
▪ Gravida: number of pregnancies
▪ Paraƒparity: number of viable pregnancies delivered regardless of outcome
□ Nulli: 0
□ Primi: 1st
□ Multi: 2−4
□ Grand multi: >5
□ <20 abortion
□ 20−36 weeks preterm delivery
□ 27−42 weeks full term delivery
□ >42 weeks post term delivery
□ Parity should be used as best obstetrical score
• 3 common dx that makes pregnancy dangerous as per DOH
○ Hpn
○ Diabetes
○ Anemia
• Pre menstrual hx
○ Age of menarche (usually at 12)
○ PMS
• Dx of pregnancy
○ Urinary pregnancy test best taken at 2 weeks after first missed period
• sƒsx
○ Presumptive
▪ subjective
○ Probable
▪ objective
○ Positive
▪ objective

Physiological adaptations to pregnancy


• Check vs
• Skin color
○ Pallor
▪ Pathologic
▪ Blood volume inc by 30−50%
▪ Normal on first tri only
np p
Hgb 12−16gƒdL <11gƒdL
hct 37−47% 33−34 %

▪ >11 normal
▪ 9− <11 mild pathologic anemia
▪ 7 but < 9 moderate pathologic anemia
▪ <7 severe pathologic anemia
• Check lower conjunctival sac, nails, lips for anemia
• Head assessment
○ Headache
○ Hair: dryness

▪ If oily, healthy
○ Face
▪ edema
▪ chloasma
□ Nose, cheek, neck
○ Nose: epistaxis
▪ dƒt high level of estrogen as it causes nasal congestion
▪ Tilt forward to prevent aspiration
○ Neck
▪ Thyroid gland is slightly enlarged
○ Chest
▪ SOB (normal)
▪ DOB (abnormal)
○ Palpitations
▪ Normal
▪ Left lateral position
○ Pyrosis is normal
▪ SFF
▪ Antacid as prescribed
• GI
○ Constipation
▪ High progesterone, decreases GI motility
▪ Inc fluid and fiber and exercise
▪ Malunggay is good
○ Striae gravidarum
▪ Stretch marks
▪ Not applicable to everyone becos others can have high levels of collagen on skin
• Musculoskeletal
○ Leg cramps
▪ Increase calcium intake
▪ Dorsiflex to relax muscles
○ Lordosis
▪ Low back pain
▪ Rest periods
▪ Flat shoes
○ Edema
▪ High amt of progesterone > increased aldosterone > fluid and sodium retention
▪ elevate
○ Varicosities
▪ Knee high stockings
• Diagnostic exams
UTZ amniocentesis
Visualization Aspiration of amniotic fluid
Non invasive Invasive
No consent With consent
Inc OFI <20w pregnancy Puncture sire at lower
>20w no need unless suspected with oligohydramnios abdomen
1 cup of water q15
1 1ƒ2 hr before utz
Total: 1140mL
Do not void Void
15−30mL of AF
• Fetal lung maturity
• Neural tube
defect
○ Spina bifida
• Chromosomal defect
○ Down syndrome

Chorionic villi sampling Maternal serum alpha fetoprotein


Determine possibility of chromosomal defect Determine possibility of chromosomal defect and neural tube defect
10−12t of pregnancy 14−16t week
h h
Obtain sample of CV Obtain maternal blood
Should be negative 38−45mgƒdl
<38: CD
>45: NTD
NTD: take FA (400mcg)

Non stress test Contraction stress test


Non stimulating Stimulate uterine contraction
Rxn of FHR to fetal movement Rxn of FHR to uterine contraction
30−32 wk of pregnancy 34−36th wk of pregnancy
(might cause premature labor if done early)
Reactive: FHR acceleration: positive Nipple rolling stimulates posterior PG to release oxy and create mild moderate
Obtain baseline VS prior to test contraction
Reactive if there is an increase of at least 15 NR doesn’t affect FHR
beats from baseline Normal: negative
check after 10mins from initial testing, FHR should not decrease
Strong UC = decreased FHR
Make sure baby is awake by making mother eat If result is inconsistent (i.e, +−+) a dominant negative result must be yielded out for
to increase glucose on fetus as it crosses PB nsvd to be allowed

Nutritional reqt during pregnancy


NP P
Caloric 2000 2300−2500
Iron 30mg 60mg
FA 400mcg
Calcium 1200mg
Phosphorus 700mg
Protein 60gm
Elemental iodine 1cap of 250mgƒpregnancy
Vitamin A 10,000IU
(not to be administered on 1st tri, rather on 4th month of preg as this has teratogenic
effect)

Ç fiber, OFI
$ salt, fats

Important estimates of delivery


• EDCƒDƒB

○ Naegele's rule = LMP − 3months + 7 days


• AOG
○ McDonald's rule
▪ AOG in weeks
□ Fundic height in cm x 8 ƒ 7
□ Put in dorsal recumbent position
□ Upper border of symphysis pubis to fundus
▪ AOG in months
□ FH in cm x 2ƒ7
▪ Bartholomew's rule
□ Locate fundus on abdomen of pregnant woman
□ 1ƒ2 half from umbilicus to symphysis pubis: 3 months
□ Slightly below umbilicus: 4months If fundus is palpable at 2 months:
□ Fundus at umbilicus: 5 months must be H mole
□ 1ƒ4 from umbilicus to xiphoid: 6 months
□ Fundus slightly above umbilicus: 7 months
□ Slightly below XP: late 8 months or 9 months
□ Fundus at xiphoid process: early 9th month of pregnancy

Lightening: dropping of the baby at the inlet


Primigravida:
1−2 weeks before labor and delivery
Multipara:
1−2 days before delivery

Labor and delivery


• Expulsion of all products of conception
• Everything else must go out or else there will be continuous bleeding
True False
Contractions are regular Irregular contraction
Intactness of BOW affects L&D Amniotomy: intentional rupture of BOW
Presence of bloody
• Done to shorten labor show Absence of bloody show
Affected by sedation Unaffected by sedation
Increased intensity No increase in intensity
Pain begins at lumbosacral area radiating to Pain confined to
abdomen abdomen
Pain intensified by walking Pain relieved by walking
Ruptured BOW Intact BOW
Cervical effacement dilation (major sign) No cervical changes
Early signs of impending labor:
• Lightening
• Nesting behavior
• Loss of appetite
• Weight loss at around 1−3lbs
• Ruptured BOW
5 P's affecting L&D
• Power
○ To push the baby out
○ Primary: uterine contractions
• Uterine contraction:
○ Increment
▪ Start of UC
○ Acme
▪ Peak of UC
○ Decrement
▪ End of UC
○ Duration
▪ Increment to decrement of one contraction
○ Interval
▪ Decrement of first to increment of second
○ Frequency
▪ Increment of first to increment of next contraction
○ Frequency
▪ Increment of first to increment of next contraction

Drugs preventing contraction:


Oxytocic (stimulate UC) Tocolytic (stop UC)
Syntocinon (IV incorporation) Bricanyl (terbutaline)
Pitocin (IV incorporation) Duvadilan
Oxytocin (IM) Dactyl OB
Methergine Yutopan
MgSO4

Don’t give syntocinonƒpitocin if there is high BP


*Pregnancy can be saved: tocolytic
*Pregnancy can no longer be saved: oxytocic
*threatened abortion: tocolytic
*premature labor that cant be stopped: oxytocic
*premature labor that can still be halted: oxytocic
*not give in fetal distress: oxy
*abruptio placenta: toco
○ Secondary: maternal pushing
▪ Panting: relax abdominal muscle
▪ Don’t push at 7cm dilatation, causes cervical tear
• Passageway
○ Pelvis
▪ Typ
e Gynecoid (best)
□ Anthropoid (2nd best)
▪ □
Size Transverse: 13 cm
□ AP: 11 cm

○ Cervical canal
▪ Dilatation
□ Fontanels
▪ Effacement ◆ Anterior fontanel is bigger than posterior
○ Vaginal canal
◆ PF closes at 2−3 months after delivery
▪ Rugae (reason why it expands) ◆ AF closes at 12−18 months
• Passenger
□ 4 regions of fetal skull
○ Number ◆ Face (biggest)
▪ 1 baby (normal) ◆ Brow (big)
○ Size
◆ Sinciput (small)
▪ 2.5−4kg (ave: ◆ Occiputƒvertex (smallest)
3kg)
○ Presentation □ Subocciput bregmatic 9.5cm
▪ Cephalic (normal) □ Mentovertical (face) 13.5 cm
▪ Breech
▪ Transverse
○ Presenting part
○ Attitude
▪ Flexion (preferred)
▪ Extension
○ Lie
▪ Long axis of uterus to long axis of
▪ fetus 2 types
□ Cephalic
▪ Long axis of uterus to long axis of fetus
▪ 2 types
□ Cephalic
□ Breech
▪ Transverse lie
▪ Oblique lie
○ Position
▪ Relationship of fetal landmark with maternal pelvic quadrant
▪ Do determine where to auscultate fetal heart rate
▪ LOA most common (80%)
▪ OP or OA if both in the middle
▪ OP LOP ROP cx:
□ Laceration
□ Lumbar pain
◆ Massage sacral area in circular motion
Q To increase O2 supply

• Placental factor
○ Type of separation
▪ Schulz (common?)
• Psyche
○ Mental, emotional preparation when undergoing delivery
○ If possible, bring COC to provide emotional support

Four s tages in labor and delivery


1. Dilatation
○ True labor to complete cervical dilatation
○ Longest because it has 3 phases
▪ Latent
▪ Active
▪ Transitional
L A T
Cervical dilatation 0−3cm 4−7cm 8−10cm
Duration <40s 40−60s 60−90s
Frequency q>5mins q3−5mins q1 1−2mins
2

Intensity Mild Moderate Strong


Mood of client Cooperate < cooperative Uncooperative

2. Expulsion
○ CCD to delivery of bb
3. Placental
○ Delivery of bb to delivery of placenta
4. Recovery
○ 1st 2−4h post delivery

Essential Intrapartum Newborn Care


• Before ENC only on 2009
• Answer for millennium devtl growth #4 and #5
• Decrease by 40% both MMR and NMR
○ However, NMR only decreased by 20% which became EINC in may 2012
• Pre pregnant updates
○ Nutritional requirement
▪ Use of iodized salt becos iodine supports brain devt
▪ 2k caloric intake
▪ 30mgƒday for iron (60mg if preggo)
▪ Increased fiber
○ Healthy lifestyle
▪ Alcohol and smoking cessation
□ Can lead to SGA if not stopped
□ No amount of alcohol is acceptable during pregnancy
▪ Regular exercise
○ Family planning
▪ Always part of post, intra, and post pregnancy
○ STI prevention
▪ Condom, abstinence and MMR
• Antepartal updates
○ Prenatal check up
▪ Facility−based
▪ Min of 4 times (4,6,8,9)
▪ COC
▪ Provide continuous maternal support
○ Healthy lifestyle
▪ Avoid alcohol, smoking
▪ STIƒSTD prevention
○ Regulated nutritional intake
○ Antenatal steroid
▪ Dexamethasone
▪ Betamethasone (preferred if both are available)
□ Timing: 24th−28th week of pregnancy
◆ Fetal alveoli begins production of surfactants at 6th month
□ Promotes fetal lung maturity
□ Recipient:
◆ If pregnant woman is at risk for preterm labor
Q Diabetic
Q Hypertensive
Q Anemic
◆ Hx of preterm labor or delivery
◆ Hx of vaginal bleeding during present pregnancy
◆ Experiencing actual preterm labor
□ Dosage
Dexamethasone Betamethasone
6mg IM q12h x 4 doses 12mg IM q24 x 2 doses
• Intrapartal update
○ COC
○ Admit client in labor room during active phase
▪ At least 4 cm of CD
○ X NPO
○ X IVT
○ X IV incorporation of oxytocic drug
○ Position: any upright position
▪ Encouraged to stand sit walk as long as BOW is intact
▪ Encourage fetal descent
▪ Shorten 1st stage of labor
○ X enema
▪ Increases uterine constriction
○ X shaving
○ Encourage bladder emptying
▪ Use (orange) SC fr 14−16
○ IE
▪ 5 or less
▪ Q4
○ Use of partograph

• Delivery room update


○ Prepare the room
▪ Temp at 25−28 degrees Celsius
▪ Eliminate air draft
▪ Turn off AC just before baby is out
○ Position:
▪ Best is upright position
○ No coached pushing
▪ Opposite is panting
○ Ritgen's Maneuver to prevent laceration
○ X brandt−andrew's maneuver
▪ Because administration of oxy
○ Active mgt of third stage of labor
▪ Controlled cord traction with counter traction
○ X cord milking
○ Oxytocin IM
▪ 1min after baby out
• 4 newborn protocols
○ Dry
▪ Tap dry to retain vernix caseosa
○ Skin to skin
▪ Promotes normal flora wƒc protects from strep and staphylococcal infection
○ Clamp and cut
▪ Milk away from baby so when you cut, blood doesn’t spurt
▪ If milked toward the baby, incoming blood may disrupt the normal cardiac flow
○ Non separation
Time Activity Objective
1st 30mins after delivery Thorough drying Prevent hypothermia
After 1st 30s Skin to skin contact (ssc) Prevent hypogly and infection
Within 1−3mins post delivery Cord clamping and cutting (ccc) Prevent anemia
Within 90mins after delivery Keep SSC (ssc) Promote BF

• Gloves 2 pieces
○ Double gloving
• Towels 2 pieces
○ Lower abdomen to catch bb
○ Towel #1 first 30 s dry the bb to prevent hypothermia
○ Towel #2 back of the bb after ssc
• Bonnet 1
○ Put bonnet after utilizing both towels
• Oxytocin
○ Don’t give if BP >140ƒ90
○ Check for possible second baby
○ Press abdomen and massage to stimulate contraction
• Cord dressing materials
○ 1−3 mins after delivery
○ Max waiting time 3 mins before clamping
○ CC 2 cm from base
○ Kelly 3cm from CC
• Empty kidney basin
○ Waste receptacle
• KB with 5% chlorine solution
○ Active mgt of TSL begins after administration of oxy Oxy: rhythmic UC
○ Disinfect placenta in this KB Methergine: sustained UC
• space for bf
• Eye prophylaxis
○ Erythromycin ophthalmic ointment
○ Inner to outer
○ Prevent ophthalmia neonatorum
▪ rƒt gonorrhea
• Vitamin K (vastus lateralis)
○ Promote blood coagulation
○ Promote blood clotting
E. Coli normal flora that stimulates clotting
• Heparin
• Hep B vaccine (vastus lateralis)
• BCG vaccine (ID)
• Stethoscope
• Tape measure
○ HC: 33−35cm
○ ACƒCC: 31−33cm
○ Birth length: 47−54cm

Postpartum
• Puerperium
○ 1st 5w period after delivery
• Involution
○ Return of uterus from pregnant to non pregnant
○ Fundus at level of umbilicus after delivery of bb and placenta
○ Height of fundus decreases one fingerbreadthƒday after delivery
○ At 10th day, fundus is no longer palpable
○ Sluggish involution if uterus descent is slow
Ways of promoting UC
• Massage fundus
• Bladder emptying
○ To prevent uterus displacement
• Early bf
• Early ambulation
○ ASAP after delivery (nsvd)
○ 24h after delivery (CS)
Haase's rule
• Determines length of the baby during pregnancy
• 1−5mos squared
○ 1x1, 2x2 and so on
• 6−9mos x 5
Johnson's rule
• Estimated fetal weight in grams
• FH in cm − 11 (or 12) x 155
○ Minus 11 if not
engaged Determined through ballotement
○ Minus 12 if engaged
Family planning
Natural Artificial
Abstinence Hormonal
Regular
Strict
Lactational amenorrhea method Chemical
6m protection from pregnancy
BF inc estrogen
Inc estrogen > APG will not release Follicle stimulating hormone
If no FSH > no ovulation
LAM must be used exclusively (regular and full time)
Fertility awareness method Surgical
• Calendar method
• Cervical mucus test
• Symptothermal method
• Basal body temp
○ Progesterone inc BT
• 2−day method
○ 2 consecutive dry days = safe
Mechanicalƒbarrier
Fertile cervical mucus
• Clear
• Watery
• Abundant
• Slippery
• Thin

Artificial
• Hormonal
• Suppressesƒinhibits ovulation

○ Levels of EƒP will remain high = no hypothalamic actƒno ABGƒno ovarian activity = no hormones released
○ Uterine activity will remain
• SƒE
• cƒI
○ >35
○ Pregnant
○ Lactating
○ HPN
○ DM
○ CV problems
○ Thromboembolic disease
○ Liver problem
• Danger signs when taking the pill
○ Jaundice
○ Abdominal pain ➢ Could indicate liver problem
○ Chest pain ➢ Heart problem
○ Headache ➢ Possible HPNƒdiabetes
○ Eye problems
○ Severe leg pain ➢ Thromboembolic disease
• Types:
○ Oral
▪ Pills are best taken during menstruation
▪ In case of a missed pill, if remembered on the same day, take 1 as usual
□ If missed a day, 2 pills a day (1AM, 1PM)
□ If missed 2 days, take 2 pills for 2 days then go on as usual
□ If missed for 3 days, discard the whole pack as this seems confusing
□ 28 day pill:
◆ 21 hormonal tablets
◆ 7 placebo pills
◆ 1 tabletƒ dayƒsame time
◆ Back to hormonal tablets after mens
◆ E+P
□ 21 day pill
◆ All hormonal tablets
◆ Categorized as POP
◆ After consuming an entire pad, rest for a week then start again after the end of mens
□ COC
◆ cƒi in BF becos it will affect milk
◆ production Estrogen and progesterone
◆ Combined oral contraceptive
□ POP
◆ Pwede for BF mother
◆ Progestogen−only contraceptive pill
○ Implant:
▪ Implanon
□ 99.8% protection
□ 3 years protection
▪ Ortho evra
□ Patch
□ 1 pack = 3 patches
□ □
□ 1 patch = 7 days
□ Rest for a week after 3
○ Injectable patches Applied on deltoid
area
96% protection
▪ Depo provera
□ Progesterone−based
□ 3 months protection
□ No mens
□ Don’t massage injection site as this increases absorption and protection timeline becomes shorter
• Chemical
• Spermicide
○ Increasing VC acidity
○ 80% efficacy rate
○ Once itchiness occurs, discontinue
○ Use with condom for increases efficacy
○ Forms:
▪ Spray
▪ Tablet
▪ Gel
▪ Foam
• Barrierƒmechanical method
• Blocks sperm from entering
• Types:
○ Condom: vaginal canal ➢ Check under the light to see if there is a hole
○ Cervical capƒdiaphragm: cervical canal ➢ Latex allergy
▪ Retain for 6−8h post sex
○ IUD: fallopian tube
▪ Sterile inflammatory response in the FT protects from pregnancy
▪ Mostly uses Copper T
IUD BTL
Done During mens During mens
Mens Continue Continue
Ovulate ƒ ƒ
Protection ƒ ƒ
STD protection X X
Permanent X ƒ

Abnormal OB
• Antepartal
○ Bleeding
▪ 1st
tri Abortion
□ Ectopic pregnancy

▪ 2nd tri
□ Abortion
□ Incompetent cervix
□ H−mole
▪ 3rd tri
□ Abruptio placenta
□ Placenta previa
▪ Assess first how many months is the gestation period
▪ Abortion occurs when there is termination before period of viability (20 weeks)
○ Abortion
▪ Types
□ Spontaneous
◆ Non intentional
◆ Types:
Q Threatened
◗ Pregnancy is in danger, but if controlled, pregnancy may continue
◗ Only type of abortion to be saved
◗ No IE
◗ Bed rest (left lateral position)
◗ Tocolytic drugs
◗ Sedative drugs are ok
Q Imminent
Q Complete
◗ Everything is out
Q Incomplete
◗ Placenta remains
◗ Uterus relaxes
Q Missed
◗ Intra uterine fetal deathƒdemise
◗ Decreasing abdominal girth
◗ Brownish vaginal discharge
◗ 4−6w staying
Q Habitualƒrecurrent
◗ 3 or more consecutive abortions
◗ Mostly caused by incompetent cervix
– Cervix cant remain close during
pregnancy
– LGA, IC are prone thereof
– Usually on 2nd tri, 4th month Painless vaginal bleeding on 3rd tri: PP
– Painless vaginal bleeding 1st,2nd tri
– Kegel's exercise
– Management:
◆ Cerclage suturing
○ Temporary: McDonald's
❖ Removed at 37w or is showing signs of true labor (whichever comes first)
○ Permanent: Shirodkar
❖ Not removed
❖ BB delivered via CS
Q Septic
◗ Incomplete and missed abortion could lead to septic abortion
◗ an infection of the placenta and fetus, or products of conception, of a pre−viable pregnancy
Q Bethametasone (celestone)
Cervix BOW UC
TA Close Intact mild
IA Open Ruptured Mild to moderate
CA
IncA
Missed
Septic
Habitual
□ Induced
◆ Intentional
◆ Types:
Q Therapeuticƒlegal
◗ Done to save life of mother
◗ E.g. cardiac condition, ectopic pregnancy
Q Non−therapeuticƒcriminal
◗ Get rid of unwanted pregnancy
○ Ectopic pregnancy
▪ Pelvic inflammatory disease (1st)
▪ IUD use (2nd)
▪ Types:
□ Tubal
◆ Common
◆ Ampulla (widest)
□ Ovarian
◆ Interstitial (narrowest)
□ Abdominal
◆ dangerous
□ Cervical
◆ Rare
▪ FT is expected to rupture between 10th−12th week
▪ Kehr's sign (best sign)
□ Sharp stabbing pain from lower quadrant of abdomen to same−side shoulder
□ Unilateral
▪ Diagnosed through UTZ
▪ DOC: methotrexate
□ Used on H−mole
▪ Surgery: ExLap followed by oophorectomy
○ H−mole
▪ Gestational trophoblastic disease
□ Over production of trophoblastic cell = more chorionic villi = more vesicles (fluid filled) = rapid enlargement of uterus
▪ Causes:
□ Poverty: protein deficiency
□ Overfertilization
▪ 4 classical signs:
□ Uterus bigger than date
□ HCG is abnormally high 1m−2m
□ No fetal signs
□ Passage of vesicles (cardinal sign)
▪ Management:
□ D&C
□ Suction and curettage
□ Avoid pregnancy for at least 1yr
□ DOC: methotrexate
3rd trimester bleeding
Placenta previa Abruptio placenta (dangerous)
Site of implantation (lower uterine segment) Timing of placental separation (early)
Painless Painful
Uterusƒabdomen soft Board−like uterusƒabdomen
No uterine contraction With uterine contraction
Bright red Dark red
Obvious bleeding (overt) (duncan) Concealed bleeding (covert) (schulz separation)
Presenting part cant be engaged Presenting part can or cant be engaged

• Placenta previa
○ Types:
▪ Total
▪ Partial
▪ Marginal
▪ Low lying
○ Dx:
▪ abdominal ultrasound
▪ Transvaginal utz
□ Determine extent of obstruction
○ Management
▪ Watchful waiting
▪ Bed rest
▪ Give celestone
▪ Emergency CS asap
▪ LLP
▪ O2 therapy
▪ IVT
▪ Blood transfusion

• Abruptio placenta
○ Causes
▪ Short umbilical cord (normal: 50−55cm)
▪ Cord coil
▪ Hypertension
▪ Unwise use of oxytocic drug
○ Mgt:
▪ Tocolytic: MgSO4 (prevent contraction)
▪ Bed rest
▪ No IE
▪ External fetal monitoring
• Pregnancy−induced hypertension
○ Classical signs:
▪ Proteinuria
▪ Edema
▪ Hypertension
□ DOC: hydralazine (apresoline)
○ Predisposing factors
▪ Primigravida, young
▪ Multi, advanced maternal age
▪ Low socio economic status
▪ Stress
▪ Diabetes
○ Protein should be slightly high in the diet
○ Promote safety in labor and delivery
○ Types:
▪ Gestational hypertension
□ High BP only
□ Starts increasing >20w and above
▪ Pre eclampsia
□ PEH BP Proteinuria Edema
□ Starts increasing >20w and above MP 140ƒ90−160ƒ110 +1, +2 Mild to moderate
□ Types:
SPE >160ƒ110 +3, +4 Severe
◆ Mild
◆ Severe E Same Same Same
▪ Eclampsia
□ PEH • Blurring of vision
□ Starts increasing >20w and above • Severe headache
▪ Chronic hypertensive disease • Hyperactive reflexes > impending convulsion
□ PEH • Epigastric pain
□ Increases even before 20w old
○ Doc of hypertension: hydralazine
○ Doc of anti convulsion: MagSO4 > decreases neuromuscular irritability > z−track (prevent SQ irritation)
▪ Loading dose: 6−10g
▪ Maintaining dose: 1−2g
▪ 1gm=1mL
▪ Use upper outer quadrant
▪ Assess: not to administer if
□ RR: <12 bradypnea
□ UO: <30mL oliguria
□ Reflexes: hypoactive <1 hyporeflexia (earliest sign)
▪ Monitor
□ Blood pressure
□ Weight
□ FHR
□ Kick count
▪ Mgt:
□ Dim lit room
□ Call light within reach
□ Quit envt
□ Side rails up padded
□ Left lateral to promote drainage of secretions
□ Indwelling catheter
• GDM
○ Caused mostly by:
▪ Estrogen
▪ Progesterone
▪ Human placental lactogen
○ Screened best at 24w
○ Types:
▪ I: Insulin dependent DM
□ Child onset
□ Insulin
□ Diet and exercise
▪ II: NIDDM
□ Diet and exercise
□ Insulin
□ Oral hypoglycemic agent
▪ III: GDM
□ Insulin
□ Oral hypoglycemic agent
▪ III: GDM
□ Mgt: Normal blood glucose at birth: 40−60mgƒdL
◆ Diet and exercise
◆ Insulin
Q Contamination: intermediate mixed in regular vial
◗ Prolonged hypoglycemia as this affects duration
Q Aspirate regular then intermediate
◗ Good effect because onset of intermediate insulin becomes earlier
Type Onset Peak Duration
Reg 30m − 1h 4h 5−8hrs
If calculating time: compute onset, peak and duration
Intermediate 2h 6−8h 12−16h
• Gravido cardiac client
○ #1 predisposing client
▪ RHD < RF < Respiratory tract infection < Group A beta hemolytic streptococcus (GABHS)
□ Mitral valve stenosis damage > chronic heart failure (left−sided)
□ Dental carries
◆ Pastaƒbunot
○ Classifications
Class Damage in sƒs Activities that trigger Limitation in Physical Method of delivery
MV sƒsx activities
I Very minimal asymptomati None None NSVD
c
II minimal sƒs Heavy activities Slight NSVD to forcep delivery
III moderate sƒs Light activities Marked Forcep delivery to therapeutic
abortion
IV severe sƒs Even at rest Complete bed rest Therapeutic abortion
○ DOC to increase pumping force of LV: digitalis therapy
▪ Decreases rate of heart contraction
▪ Increased urine output
○ Best anticoagulant drug for preggo women:
▪ Heparin
□ Hindi nag cross sa PB

Post partum complications


• PP bleeding
○ Normal blood loss: 500cc
○ CS: 1L
○ Types:
▪ Early PPB
□ First 24h after delivery
□ Causes:
◆ Uterine atony
Q Uterus cant contract
Q If there is hyperdistended uterus during pregnancy:
◗ Multiple pregnancy
◗ LGA
◗ Polyhydramnios
Q Massage
Q Bed rest
Q Breastfeed
Q Bladder emptying
Q DOC: oxytocin or methergine
Q Hysterotomy if meds don’t work
◆ Lacerations
Q Degrees
◗ 1st: skin and mm of perineum
◗ 2nd: mm to muscle of perineum
◗ 3rd: mm > muscle of perineum > external sphincter
◗ 4th: mm > muscle of perineum > external > internal sphincter
Q Episiorrhaphy
◆ Retained placental fragment
Q D&C
Uterus Source of bleeding Color
UA Relaxed Uterus Dark red
L Contracted Birth canal Bright red
RPF Contracted to Uterus Dark red
relax
▪ Late PPB
• Infection
○ After 1st 24h post delivery
○ Causes:
▪ Subinvolution
□ Puerperial sepsis
◆ First affected layer is endometrium
Q Rubra: 1−3
◗ Dark red
◗ If extended: atony
◗ If early pinkish: endometritis
– Staphylococcus aureus
– E.coli (common)
– SƒSx:
◆ Brownish lochia
◆ Foul smell
◆ Fever
◆ Abdominal tenderness
Q Serosa: 4−7
◗ Pinkish to brown
Q Alba 8−14
◗ Whitish to clear
Q Management:
◗ Fowler's to drain infected lochia
◗ Do not massage
◗ Continue BF
◗ Antibiotic
◗ Analgesic
◗ Anti inflammatory
◗ Anti pyretic

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