ANGEL ALBERT F.

LAMBAN, RN, MD

Human Sexuality
Concepts
A

persons sexuality encompasses the complex behaviors, attitudes emotions and preferences that are related to sexual self and eroticism

Sex basic and dynamic aspect of life During reproductive years, the nurse performs as

resource person on human sexuality.

Definitions related to sexuality:

Gender identity sense of femininity or masculinity 2-4 yrs/3 yrs gender identity develops Role identity attitudes, behaviors and attributes that

differentiate roles
Sex biologic male or female status. Sometimes referred to

specific sexual behavior such as sexual intercourse.

Sexuality - behavior of being boy or girl, male or female

man/

woman. Entity life long dynamic change.

- developed at the moment of conception

Sexual Anatomy and Physiology

A. Female Reproductive System

1. External value or pretender

a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis.

Stages of Pubic Hair Development

Tannerscale tool - used to determine sexual maturity rating. Stage 1 Pre-adolescence. No pubic hair. Fine body hair only
Stage 2 Occurs between ages 11 and 12 sparse, long, slightly

pigmented & curly hair at pubis symphysis

Stage 3 occurs between ages 12 and 13 darker & curlier at labia Stage 4 occurs between ages 13 and 14, hair assumes the normal

appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh
Stage 5 sexual maturity- normal adult- appear inner aspect of upper

thigh .

 b. Labia Majora - large lips longitudinal fold, extends

symphisis pubis to perineum

c. Labia Minora 2 sensitive structures
clitorisanterior, pea shaped erectile tissue with lots of sensitive nerve endings; sight of sexual arousal (Greek-key) fourchettePosterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during delivery. Site episiotomy

d. Vestibule an almond shaped area that contains the

hymen, vaginal orifice and bartholenes glands.

anus

e. Perineum muscular structure loc lower vagina &

 Urinary Meatus small opening of urethra, serves for urination Skenes glands/or paraurethral gland mucus secreting subs for

lubrication

hymen covers vaginal orifice, membranous tissue vaginal orifice external opening of vagina bartholenes glands - paravaginal gland or vulvo vaginal gland -2

small

mucus secreting subs secretes alkaline substance

Alkaline neutralizes acidity of vagina Ph of vagina - acidic Doderleins bacillus responsible for acidity of vagina Carumculae mystiformes - healing of torn hymen

2. Internal
A. vagina female organ of copulation, passageway of mens & fetus, 3

4inches or 8 10 cm long, dilated canal Rugae permits stretching without tearing

B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights.
Size- 1x2x3
Shape: nonpregnant pear shaped / pregnant ovoid Weight - nonpregnant 50 -60 g- pregnant 1,000g

Pregnant/ Involution of uterus:

4th stage of labor 2 weeks after delivery 3 weeks after delivery 5-6 weeks after delivery

-1000g - 500g - 300 g - returns to original, state 50 60 gms

Three parts of the uterus

fundus corpus/body cervix

- upper cylindrical layer - upper triangular layer - lower cylindrical layer

* Isthmus lower uterine segment during pregnancy Cornua-junction between fundus & interstitial

Muscular compositions:
there are three main muscle layers which make expansion possible in every direction.
Endometrium- inside uterus, lines the nonpregnant uterus.

Muscle layer for menstruation. Sloughs during menstruation.

 Endometriosis - proliferation of endometrial lining outside

uterus.

Common site: ovary.

S/sx: dysmennorhea, low back pain. Dx: biopsy Laparoscopy Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit ovulation 2. Lupreulide (Lupron) inhibit FSH/LH production

 Myometrium largest part of the uterus, muscle layer for delivery process

Its smooth muscles are considered to be the living ligature of the body
Power of labor, resp- contraction of the uterus

Perimetrium protects entire uterus

 c. ovaries 2 female sex glands, almond shaped.

Function:

1. ovulation 2. Production of hormones

d. Fallopian tubes 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 1. Infundibulum distal part of FT, trumpet or funnel shaped, swollen at ovulation 2. Ampulla outer 3rd or 2nd half, site of fertilization 3. Isthmus site of sterilization bilateral tubal ligation 4. Interstitial site of ectopic pregnancy most dangerous

B. Male Reproductive System

1. External
Penis

the male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female the glands penis.
3 Cylindrical Layers 2 corpora cavernosa 1 corpus spongiosum

 Scrotum

a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which contains a testes.

cooling mechanism of testes < 2 degrees C than body temp. Leydig cell release testosterone

2. Internal
The Process of Spermatogenesis maturation of sperm

Male and Female homologues

Male
Penile glans Penile shaft Testes Prostate Cowpers Glands Scrotum

Female
Clitoral glans Clitorial shaft Ovaries Skenes gands Bartholin's glands Labia Majora

III. Basic Knowledge on Genetics and Obstetrics

DNA carries genetic code

Chromosomes threadlike strands composed of hereditary material DNA Normal amount of ejaculated sperm 3 5 cc., 1 tsp

Ovum is capable of being fertilized with in 24 36 hrs after ovulation

Sperm is viable within 48 72 hrs, 2-3 days

Reproductive cells divides by the process of meiosis

Spermatogenesis maturation of sperm

Oogenesis maturation of ovum Gematogenesis formation of 2 haploid into diploid 23 + 23 = 46 or diploid Age of Reproductivity 15 44yo Menstrual Cycle beginning of mens to beginning of next mens Average Menstrual Cycle 28 days

Related terminologies: Menarche 1st mens Dysmenorrhea painful mens Metrorrhagia Menorhagia Amenorrhea Menopause bleeding between mens excessive during mens absence of mens cessation of mens/ average : 51 years old

 * Estrogen Hormone of the Woman

Primary function: development secondary sexual characteristic

female.

Others:

inhibit production of FSH ( maturation of ovum) hypertrophy of myometrium Spinnbarkeit & Ferning ( billings method/ cervical) development ductile structure of breast increase osteoblast activities of long bones increase in height in female causes early closure of epiphysis of long bones causes sodium retention increase sexual desire

 *Progestin Hormone of the Mother

Primary function:

prepares endometrium for implantation of fertilized ovum making it thick & tortous

Secondary Function:

pregnancy)

uterine

contractility

(favors

Others: inhibit prod of LH (hormone for ovulation) inhibit motility of GIT mammary gland development increase permeability of kidney to lactose & dextrose causing (+) sugar causes mood swings in moms increase BBT

Menstrual Cycle
4 Phases of Menstrual Cycle 1. Proliferative 2. Secretory 3. Ischemic 4. Menses Parts of body responsible for mens: hypothalamus anterior pituitary gland master clock of body ovaries uterus

 Initial phase 3rd day decreased estrogen 13th day peak estrogen, decrease progesterone

14th day Increase estrogen, increase progesterone

15th day Decrease estrogen, increase progesterone

 On the initial 3rd phase of menstruation , the estrogen

level is decreased, this level stimulates hypothalamus to release GnRH or FSHRF

to release FSH

the

GnRH/FSHRF stimulates the anterior pituitary gland

Functions of FSH: Stimulate ovaries to release estrogen

Facilitate growth primary follicle to become graffian follicle

(secretes large amt estrogen & contains mature ovum.)

Proliferative Phase
proliferation of tissue or follicular phase, post mens phase. Pre-ovulatory.

-phase of increase estrogen.

Follicular Phase causing irregularities of mens Postmenstrual Phase Preovulatory Phase phase increase estrogen

Proliferative Phase
13th day of menstruation, estrogen level is peak while the

progesterone level is down, these hypothalamus to release GnRF on LHRF abdomen, marks ovulation day.

stimulates

the

Mittelschmerz slight abdominal pain on L or RQ of

Change in BBT, mood swing

GnRF/LHRF stimulates the ant pit gland to release LH.

Proliferative Phase
Functions of LH:
(13th day-decreased progesterone) LH stimulates ovaries

to release progesterone hormone for ovulation

14th

day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of ovulation.

15th day, after ovulation day, graafian follicle starts to

degenerate yellowish known as corpus luteum (secrets large amount of progesterone)

Secretory Phase
Lutheal Phase Postovulatory PhaseIncreased progesterone Premenstrual Phase

24th day if no fertilization, corpus luteum degenerate (

whitish corpus albicans) slough off to begin mens

28th day if no sperm in ovum endometrium begins to

Secretory Phase
Cornix- where sperm is deposited
Sperm- small head, long tail, pearly white Phonones-vibration of head of sperm to determine

location of ovum

Sperm should penetrate corona radiata and zona pellocida.

Capacitation- ability of sperm to release proteolytic

enzyme to penetrate corona radiata and zona pellocida.

Stages of Sexual Responses (EPOR)

Initial responses:

Vasocongestion congestion of blood vessels Myotonia increase muscle tension

Excitement Phase (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) erotic stimuli cause increase sexual tension, lasts minutes to hours.

Plateau Phase (accelerated V/S) increasing & sustained tension nearing orgasm. Lasts 30 seconds 3 minutes.

Stages of Sexual Responses (EPOR)

Orgasm (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with physiologic or psychologic release, immeasurable peak of sexual experience. May last 2 10 sec- most affected are is pelvic area.
Resolution (v/s return to normal, genitals return to pre-excitement phase) Refractory Period the only period present in males, wherein he cannot be restimulated for about 10-15 minutes

Fertilization
Stages of Fetal Growth and Development
3-4 days travel of zygote mitotic cell division begins

Fertilization
A. Pre-embryonic Stage
a. Zygote - fertilized ovum. Lifespan of zygote from fertilization to 2 months

b. Morula mulberry-like ball with 16 50 cells, 4 days free floating & multiplication
c. Blastocyst enlarging cells that forms a cavity that later becomes the embryo. covering of blastocys that later becomes placenta & trophoblast d. Implantation/ Nidation- occurs after fertilization 7 10 days.

Fertilization
B. Fetus
- 2 months to birth.

placenta previa implantation at low side of uterus

Signs of implantation: 1. slight pain 2. slight vaginal spotting - if with fertilization corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed.

Fertilization
3 processes of Implantation 1. Apposition 2. Adhesion 3. Invasion

C. Decidua thickened endometrium ( Latin falling off)

Basalis (base) part of endometrium located under fetus where placenta is delivered Capsularies encapsulate the fetus Vera remaining portion of endometrium.

D. Chorionic Villi- 10 11th day, finger life projections 3 vessels= A unoxygenated blood V O2 blood A unoxygenated blood

Whartons jelly protects cord

Chorionic villi sampling (CVS) removal of tissue sample from the fetal portion of the developing placenta for genetic screening Done early in pregnancy Common complication fetal limb defect. Ex missing digits/toes. E. Cytotrophoblast inner layer or langhans layer protects fetus against syphilis 24 wks/6 months life span of langhans layer increase. - Before 24 weeks critical, might get infected syphilis

F. Syncitiotrophoblast synsitial layer responsible production of hormone

1. Amnion inner most layer a. Umbilical Cord whitish grey, 15 55cm, 20 21

Short cord: abruptio placenta or inverted uterus

Long cord:cord coil or cord prolapse

bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline.

b. Amniotic Fluid

*Function of Amniotic Fluid: 1. cushions fetus against sudden blows or trauma 2. facilitates musculo-skeletal development 3. maintains temp 4. prevent cord compression 5. help in delivery process
normal amt of amniotic fluid 500 to 1000cc

polyhydramnios, hydramnios - GIT malformation TEF/TEA, increased amt of fluid

oligohydramnios - decrease amt of fluid kidney disease

Diagnostic Tests for Amniotic Fluid

A. Amniocentesis empty bladder before performing the procedure.

Purpose obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for: Genetic screening maternal serum alpha feto-protein (MSAFP) - Determination of fetal maturity primarily by evaluating factors indicative of lung maturity

test

Diagnostic Tests for Amniotic Fluid

Testing time 36 weeks
decreased MSAFP = down syndrome increase MSAFP = spina bifida or open neural tube defect

Common complication of amniocentesis infection

Diagnostic Tests for Amniotic Fluid

Dangerous complications spontaneous abortion
3rd trimester - pre term labor Important factor to consider for amniocentesis - needle insertion site

Aspiration of yellowish amniotic fluid jaundice baby

Greenish meconium

Amnioscopy direct visualization or exam to an intact fetal membrane. Fern Test - determine if amniotic fluid has ruptured or not - blue paper turns green/grey - + ruptured amniotic fluid Nitrazine Paper Test - diff amniotic fluid & urine. - Paper turns yellow- urine. - Paper turns blue green/gray-(+) rupture of amn fluid.

Chorion where placenta is developed

Lecithin Sphingomyelin L/S Ratio- 2:1 signifies fetal lung maturity not capable for RDS Phosphatidylglycerol : PG+ definitive test to determine fetal lung maturity

Placenta (Secundines) Greek

pancake, combination of chorionic villi + deciduas basalis. - Size: 500g or kg

-1 inch thick & 8 diameter

Functions of Placenta: Respiratory System

beginning of lung function after birth of baby. Simple diffusion

GIT transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic Excretory System - artery - carries waste products. Liver of mom detoxifies fetus. Circulating system achieved by selective osmosis

 Endocrine System produces hormones

Human Chorionic Gonadrophin maintains corpus luteum alive. Human placental Lactogen or sommamommamotropin Hormone for mammary gland development. Has a diabetogenic effect serves as insulin antagonist Relaxin Hormone- causes softening joints & bones estrogen progestin barrier against some

It

serves as a protective microorganisms HIV,HBV

Fetal Stage Fetal Growth and Development

Entire pregnancy days 266 280 days 37 42 weeks Differentiation of Primary Germ layers Endoderm 1st week endoderm primary germ layer Thyroid for basal metabolism Parathyroid - for calcium Thymus development of immunity Liver lining of upper RT & GIT

Mesoderm development of heart, musculoskeletal system, kidneys and repro organ

Ectoderm development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth

First trimester:

1st month Brain & heart development GIT& resp Tract remains as single tube
1. Fetal heart tone begins heart is the oldest part of

the body 2. CNS develops dizziness of mom due to hypoglycemic effect Food of brain glucose complex CHO pregnant women food (potato)

First trimester:

Second Month All vital organs formed, placenta developed Corpus luteum source of estrogen & progesterone of infant life span end of 2nd month Sex organ formed Meconium is formed

First trimester:

Third Month Kidneys functional Buds of milk teeth appear Fetal heart tone heard Doppler 10 12 weeks Sex is distinguishable

Second trimester:
FOCUS length of fetus

Fourth Month lanugo begins to appear fetal heart tone heard fetoscope, 18 20 weeks buds of permanent teeth appear

Second trimester:

Fifth Month lanugo covers body actively swallows amniotic fluid 19 25 cm fetus, Quickening- 1st fetal movement. 18- 20 weeks primi, 1618 wks multi fetal heart tone heard with or without instrument

Second trimester:

Sixth Month eyelids open wrinkled skin vernix caseosa present

Third trimester:
Period of most rapid growth. FOCUS: weight of fetus

Seventh Month development of surfactant lecithin Eighth Month lanugo begin to disappear sub Q fats deposit Nails extend to fingers

Third trimester:

Ninth Month lanugo & vernix caseosa completely disappear Amniotic fluid decreases Tenth Month bone ossification of fetal skull

Terratogens any drug, virus or irradiation, the exposure to such may cause damage to the fetus

Drugs: Streptomycin anti TB & or Quinine (anti malaria) damage to 8th cranial nerve poor hearing & deafness Tetracycline staining tooth enamel, inhibit growth of long bone Vitamin K hemolysis (destr of RBC), hyperbilirubenia or jaundice Iodides enlargement of thyroid or goiter Thalidomides Amelia or pocomelia, absence of extremities

 Steroids cleft lip or palate Lithium congenital malformation Alcohol lowered weight (vasoconstriction on mom), fetal

alcohol withdrawal syndrome char by microcephaly

Smoking low birth rate Caffeine low birth rate Cocaine low birth rate, abruption placenta

TORCH (Terratogenic) Infections viruses

CHARACTERISTICS
group of infections caused by organisms that can cross

the placenta or ascend through birth canal and adversely affect fetal growth and development

These infections are often characterized by vague,

influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement)

In some chases the infection may go unnoticed in the

pregnant woman yet have devastating effects on the fetus virus, Herpes simples virus.

TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo

T toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meat O others. Hepa A or infectious heap oral/ fecal (hand washing) Hepa B, HIV blood & body fluids Syphilis R rubella German measles congenital heart disease (1st month) normal rubella titer 1:10

<1:10 less immunity to rubella, after delivery, mom will be given rubella vaccine. Dont get pregnant for 3 months. Vaccine is terratogenic

C cytomegalo virus
H herpes simplex virus

Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes

1. Cardiovascular System increase blood volume of mom (plasma blood) 30 50% = 1500 cc of blood - easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis due to hyperemia of nasal membrane palpitation,

Physiologic Anemia pseudo anemia of pregnant women

A. Systemic Changes

Normal Values Hct 32 42% Hgb 10.5 14g/dL Criteria 1st and 3rd trimester. - pathologic anemia if lower, HCT should not be 33%, Hgb should not be < 11g/dL 2nd trimester Hct should not <32% - Hgb Shdn't < 10.5% pathologic anemia if lower

Pathologic Anemia
iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women.
- Assessment reveals:
Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive anemia)

due to chronic physio hypoxia

Pathologic Anemia

Nursing Care: Nutritional instruction kangkong, liver due to ferridin content, green leafy vegetablealugbati,saluyot, malunggay, horseradish, ampalaya

Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if improperly administered, hematoma Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs after, black stool, constipation Monitor for hemorrhage

Pathologic Anemia

Alert: Iron from red meats is better absorbed iron form other sources

Iron is better absorbed when taken with foods high in Vit 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 lower extremities due venous return is constricted due to large belly, elevate legs above hip level.
Varicosities pressure of uterus
use support stockings, avoid wearing knee high socks use elastic bandage lower to upper

Vulvar varicosities- painful, pressure on gravid uterus, to relieve- position side lying with pillow under hips or modified knee chest position

 Thrombophlebitis presence of thrombus at inflamed

blood vessel pregnant mom hyperfibrinogenemia increase fibrinogen increase clotting factor thrombus formation candidate dorsiflexion

outstanding sign (+) Homan's sign pain on calf during milk leg skinny white legs due to stretching of skin

caused by inflammation or phlagmasia albadolens

Edema
Mgt:
Bed rest Never massage Assess + Homan sign once only might dislodge

thrombus Give anticoagulant to prevent additional clotting (thrombolytics will dilute) Monitor APTT antidote for Heparin toxicity, protamine sulfate Avoid aspirin! Might aggravate bleeding.

Respiratory system common problem SOB due to enlarged uterus & increase O2 demand Position- lateral expansion of lungs or side lying position. Gastrointestinal 1st trimester change Morning Sickness nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon small freq feeding. Vomiting in pregnancy hyperemesis gravidarum Metabolic alkalosis, F&E imbalance primary med mgt replace fluids. Monitor I&O

constipation progesterone resp for constipation

Increase fluid intake, increase fiber diet - fruits papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.
Except guava has pectin thats constipating veg petchy, malungay. - exercise -mineral oil excretion of fat soluble vitamins * Flatulence avoid gas forming food cabbage

* Heartburn or pyrosis reflux of stomach content to esophagus - small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical increase salivation ptyalsim mgt mouthwash *Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for comfort

Urinary System frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos mgt for nocturia Acetyace test albumin in urine Benedicts test sugar in urine Musculoskeletal Lordosis pride of pregnancy Waddling Gait awkward walking due to relaxation causes softening of joints & bones Prone to accidental falls wear low heeled shoes

Leg Cramps causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause while pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus Management|: Increase Ca diet-milk(Inc Ca & Inc phosphorus)1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab. Vit D for increased Ca absorption

B. Local Changes

Local change: Vagina: V Chadwicks sign blue violet discoloration of vagina C Goodel's sign change of consistency of cervix I Hegar's change of consistency of isthmus (lower uterine segment)

B. Local Changes

LEUKORRHEA whitish gray, mousy odor discharge ESTROGEN hormone, resp for leucorrhea OPERCULUM mucus plug to seal out bacteria. PROGESTERONE hormone responsible for operculum PREGNANT acidic to alkaline change to protect bacterial growth (vaginitis)

Problems Related to the Change of Vaginal Environment:

Vaginitits trichomonas vaginalis due to alkaline environment of vagina of pregnant mom Flagellated protozoa wants alkaline
S&Sx: Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema Mgt: FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so dont give at 1st trimester treat dad also to prevent reinfection no alcohol has antibuse effect VAGINAL DOUCHE IQ H2O : 1 tbsp white vinegar

Problems Related to the Change of Vaginal Environment:

Moniliasis or candidiasis due to candida albecans, fungal infection. Color white cheese like patches adheres to walls of vagina.
Signs & Symptoms: Management antifungal Nistatin, genshan violet, cotrimaxole, canesten Gonorrhea -Thick purulent discharge Vaginal warts- condifoma acuminata due to papilloma virus Mgt: cauterization

 Abdominal Changes
striae gravidarium (stretch marks) due enlarging

uterus-destruction of sub Q tissue avoid scratching, use coconut oil, umbilicus is protruding
Skin Changes

brown pigmentation nose chin, cheeks chloasma melasma due to increased melanocytes. Brown pinkish line- linea nigra- symphisis pubis to

umbilicus

 Breast Changes
increase hormones, color of areola & nipple pre colostrums present by 6 weeks, colostrums at 3rd

trimester

Breast self exam

7 days after mens supine with pillow at back quadrant B upper outer common site of cancer

 Presumptive

Breast changes Urinary freq Fatigue Amenorrhea Morning sickness Enlarged uterus Chloasma Linea negra Increased skin pigmentation Striae gravidarium Quickening

 Probable

Goodel's- change of consistency of cervix Chadwicks- blue violet discoloration of vagina Hegar's- change of consistency of isthmus Elevated BBT due to increased progesterone Positive HCG or (+)preg test

Ballottement bouncing of fetus when lower uterine is

tapped sharply Enlarged abdomen Braxton Hicks contractions painless irregular contractions

 Positive
Ultrasound evidence (sonogram) full bladder

Fetal heart tone Fetal movement Fetal outline Fetal parts palpable

Test to determine breast cancer:

1. mammography 35 to 49 yrs once every 1 to 2 yrs 50 yrs and above 1 x a yr

Ovaries rested during pregnancy

Signs & symptoms of Pregnancy
Presumptive s/s felt and observed by the mother but does

not confirm positive diagnosis of pregnancy . Subjective Objective

Probable signs observed by the members of health team. Positive Signs undeniable signs confirmed by the use of

instrument.

 Ballotment sign of myoma

* + HCG sign of H mole - trans vaginal ultrasound. Empty bladder - ultrasound full bladder

placental grading rating/grade

o immature 1 slightly mature 2 moderately mature 3 placental maturity

Psychological Adaptation to Pregnancy (Emotional response of mom Reva Rubin theory)

First Trimester: No tangible signs & sx, surprise, ambivalence, denial sign of maladaptation to

pregnancy. Developmental task is to accept biological facts of pregnancy Focus: bodily changes of preg, nutrition

Second Trimester tangible S&Sx. mom identifies fetus as a separate entity due to presence of

quickening, fantasy. Developmental task accept growing fetus as baby to be nurtured. Health teaching: growth & development of fetus.

Psychological Adaptation to Pregnancy

Third Trimester: - mom has personal identification on

appearance of baby

Development task: prepare of birth & parenting of child. HT: responsible parenthood babys Layette best time to do shopping. Most common fear let mom listen to FHT to allay fear Lamaze classes

Pre-Natal Visit:
1.

Frequency of Visit: 1st 7 months 1x a month 8 9 months 2 x a month 10 once a week post term 2 x a week

2. Personal data

name, age (high risk < 18 & >35 yrs old) record to determine high risk HBMR. Home base moms record. Sex ( pseudocyesis or false pregnancy on men & women)

Couvade syndrome dad experiences what mom goes through lihi) Address, civil status, religion, culture & beliefs with respect, non judgmental Occupation financial condition or occupational hazards, education background level knowledge

3. Diagnosis of Pregnancy urine exam to detect HCG at 40 100th day. 60 70 day peak HCG. 6 weeks after LMP- best to get urine exam. Elisa test test for preg detects beta subunit of HCG as early as 7 10days Home preg kit do it yourself

4. Baseline Data: V/S esp. BP, monitor wt. (increase wt 1st

sign preeclampsia)

Weight Monitoring First Trimester: Normal Weight gain 1.5 3 lbs (.5 1lb/month) Second trimester: normal weight gain 10 12 lbs (4 lbs/month) (1 lb/wk)

 Third trimester:
normal weight gain 10 12 lbs ( 1lb/wk)

(4 lbs/ month)

Minimum wt gain 20 25 lbs

Optimal wt gain

25 35 lbs

5. Obstetrical Data:

nullipara no pregnancy Gravida- # of pregnancy Para - # of viable pregnancy Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age. age of viability Term Preterm abortion 20 24 wks 37 42 wks, 20 37 weeks <20 weeks

Important Estimates:

Nageles Rule use to determine expected date of delivery Get LMP -3+ 7 +1 Apr-Dec LMP Jan Feb Mar M D Y +9 +7 no year

LMP Jan 25, 04 +9 +7 10 / 32 / 04 - 1 add 1 month to month 11/31/04 EDD

 McDonalds Rule to determine age of gestation IN WEEKS

FUNDIC HT X 7/8=AOG in WK

From symphysis pubis to fundus

 Bartholomews Rule to determine age of gestation

by proper location of fundus at abdominal cavity. 3 months 5 months 9 months 10 months above sym pub level of umbilicus below xiphoid level of 8 months due to lightening

 Haases rule to determine length of the fetus in cm.

Formula: 1st of preg , square @ month 2nd of preg, x @ month by 5

3mos x 3 = 9cm 4 mos x 4 = 16 cm

5 x 5 = 25 cm 6 x 5 = 30 cm 7 x 5 = 35 cm 8 x 5 = 40 cm 9 x 5 = 45 cm

1st of preg

2nd of preg

 tetanus immunizations prevents tetanus neonatum

-mom with complete 3 doses DPT young age considered as TT1 & 2.

Begin TT3

TT1 any time during pregnancy TT2 4 wks after TT1 3 yrs protection TT3 6 months after TT2 5 yrs protection TT4 1 yr after TT3 10 yrs protection TT5 yr after TT4 lifetime protection

 Physical Examination:

A. Examine teeth: sign of infection Danger signs of Pregnancy

C - chills/ fever infection

Cerebral disturbances ( headache preeclampsia)

A abdominal pain ( epigastric pain aura of

impending convulsions

Danger signs of Pregnancy

B boardlike abdomen abruption placenta

Increase BP HPN

Blurred vision preeclampsia Bleeding 1st trimester, abortion, ectopic pre/2nd H mole, incompetent cervix 3rd placental anomalies

S sudden gush of fluid PROM (premature rupture of

membrane) prone to inf.

E edema to upper ext. (preeclampsia)

 Pelvic Examination internal exam

empty bladder universal precaution

EXT OS of cervix site for getting specimen Site for cervical cancer
Pap Smear cervical cancer
- composed of squamous columnar tissue

 Result:
Class I normal Class IIA acytology but no evidence of malignancy

B suggestive of infl.
Class III cytology suggestive of malignancy

Class IV cytology strongly suggestive of malignancy

Class V cytology conclusive of malignancy

 Stages of Cervical Cancer

Stage 0 carcinoma insitu 1 cancer confined to cervix 2 - cancer extends to vagina 3 pelvis metastasis 4 affection to bladder & rectum

7. Leopolds Maneuver Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone - use palm! Warm palm.
Prep mom:
Empty bladder Position of mom-supine

with knee flex (dorsal recumbent to relax abdominal muscles)

 Procedure:
1st maneuver: place patient in supine position with

knees slightly flexed; put towel under head and right hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part to determine presentation the back of the fetus ( to hear fetal heart sound) where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver) PR to diff fundic souffl (FHR) & uterine souffl. Uterine souffl maternal H rate

2nd Maneuver: with both hands moving down, identify

 Procedure:
3rd Maneuver: using the right hand, grasp the symphis pubis

part using thumb and fingers. To determine degree of engagement.

Assess whether the presenting part is engaged in the pelvis Alert : if the head is engaged it will not be movable).
4th Maneuver: the Examiner changes the position by facing

the patients feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude relationship of fetus to 1 another.

 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 will be flexed and vertex presenting.

Attitude relationship of fetus to a part or degree of

flexion

Full flexion when the chin touches the chest

8.Assessment of Fetal Well-Being

Daily Fetal Movement Counting (DFMC)

begin 27 weeks Mom- begin after meal breakfast

a. Cardiff count to 10 method one method currently

available

(1) Begin at the same time each day (usually in the morning,

after breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs)

(2) Expected findings 10 movements in 1 hour or less

 Warning signs

a.) more then 1 hour to reach 10 movements b.) less then 10 movements in 12 hours(non-reactive- fetal distress) c.) longer time to reach 10 FMs than on previous days d.) movement are becoming weaker, less vigorous Movement alarm signals - < 3 FMs in 12 hours

warning signs should be reported to healthcare provider

immediately; often require further testing. Examples: nonstress test (NST), biophysical profile (BPP)

 Nonstress test to determine the response of the fetal heart

rate to activity

Indication pregnancies at risk for placental insufficiency

Postmaturity pregnancy induced hypertension (PIH), diabetes warning signs noted during DFMC maternal history of smoking, inadequate nutrition

Procedure:
Done within 30 minutes wherein the mother is in semi-

fowlers position (w/ fetal monitor); 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 20 minutes

if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen if no FM after 1 hour further testing may be indicated, such as a CST

 Result:

Noncreative Nonstress Not Good Reactive Responsive is Real Good

 Interpretation of results

Reactive result
Baseline FHR between 120 and 160 beats per minute At least two accelerations of the FHR of at least 15 beats per

minute, lasting at least 15 seconds in a 10 to 20 minute period as a result of FM

Good variability normal irregularity of cardiac rhythm

representing a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip

 Interpretation of results

Nonreactive result
Stated criteria for a reactive 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
Nutrition do nutritional assessment daily food intake
High risk moms:

Pregnant teenagers low compliance to heath regimen

Extremes in wt

underweight, over wt candidate for HPN, DM

Low socio economic status

Vegetarian mom

decrease CHON needs Vit B12 cyanocobalamin formation of folic acid needed for cell DNA & RBC formation.

Recommended Nutrient Requirement that increases During Pregnancy

Calories
Nutrients Essential to supply energy for

increased metabolic rate utilization of nutrients protein sparing so it can be used for Growth of fetus Development of structures required for pregnancy including placenta, amniotic fluid, and tissue growth.

Recommended Nutrient Requirement that increases During Pregnancy

Calories
Requirements 300 calories/day above the prepregnancy daily requirement
Begin increase in second trimester Use weight gain pattern as an indication of adequacy of

to maintain ideal body weight and meet energy requirement to activity level
calorie intake. Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage.

Recommended Nutrient Requirement that increases During Pregnancy

Calories
Food Source Caloric increase should reflect Foods of high nutrient value such as protein, complex carbohydrates (whole grains, vegetables, fruits) Variety of foods representing foods sources for the nutrients requiring during pregnancy No more than 30% fat

Recommended Nutrient Requirement that increases During Pregnancy

Protein
Nutrients Essential for:

Fetal tissue growth Maternal tissue growth including uterus and breasts Development of essential pregnancy structures Formation of red blood cells and plasma proteins * Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH)

Recommended Nutrient Requirement that increases During Pregnancy

Protein
Requirements 60 mg/day or an increase of 10% above daily requirements

for age group

Adolescents have a higher protein requirement than

mature women since adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement

Recommended Nutrient Requirement that increases During Pregnancy

Protein
Food Source Protein increase should reflect

Lean meat, poultry, fish Eggs, cheese, milk Dried beans, lentils, nuts Whole grains * vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids

Recommended Nutrient Requirement that increases During Pregnancy

Calcium-Phosphorous
Nutrients Essential for
Growth and development of fetal skeleton and tooth

buds Maintenance of mineralization of maternal bones and teeth Current research is : Demonstrating an association between adequate calcium intake and the prevention of pregnancy induce hypertension

Recommended Nutrient Requirement that increases During Pregnancy

Calcium-Phosphorous
Requirements Calcium increases of
1200 mg/day representing an increase of 50% above

prepregnancy daily requirement. 1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous

Recommended Nutrient Requirement that increases During Pregnancy

Calcium-Phosphorous
Food Source Calcium increases should reflect:
dairy products : milk, yogurt, ice cream, cheese, egg

yolk whole grains, tofu green leafy vegetables canned salmon & sardines w/ bones Ca fortified foods such as orange juice Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood

Recommended Nutrient Requirement that increases During Pregnancy

Iron
Nutrients Essential for
Expansion of blood volume and red blood cells

formation Establishment of fetal iron stores for first few months of life

Recommended Nutrient Requirement that increases During Pregnancy

Iron
Requirements 30 mg/day representing a doubling of the pregnant daily

requirement Begin supplementation at 30- mg/day in second trimester, since diet alone is unable to meet pregnancy requirement 60 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin values prior to pregnancy or who have iron deficiency anemia.

Recommended Nutrient Requirement that increases During Pregnancy

Iron
Requirements

mg/day of vitamin C which enhances iron absorption inadequate iron intake results in maternal effects anemia depletion of iron stores, decreased energy and appetite, cardiac stress especially labor and birth fetal effects decreased availability of oxygen thereby affecting fetal growth * iron deficiency anemia is the most common nutritional disorder of pregnancy.

70

Recommended Nutrient Requirement that increases During Pregnancy

Iron
Food Source Iron increases should reflect

liver, red meat, fish, poultry, eggs enriched, whole grain cereals and breads dark green leafy vegetables, legumes nuts, dried fruits vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage, potatoes iron from food sources is more readily absorbed when served with foods high in vit C

Recommended Nutrient Requirement that increases During Pregnancy

Zinc
Nutrients Essential for
* the formation of enzymes * maybe important in the prevention of congenital

malformation of the fetus.

Recommended Nutrient Requirement that increases During Pregnancy

Zinc
Requirements 15mcg/day representing an increase of 3 mg/day over

prepreganant daily requirements.

Recommended Nutrient Requirement that increases During Pregnancy

Zinc
Food Source Zinc increases should reflect

liver, meats shell fish eggs, milk, cheese whole grains, legumes, nuts

Recommended Nutrient Requirement that increases During Pregnancy

Folic Acid, Folacin, Folate
Nutrients Essential for
formation of red blood cells and prevention of anemia DNA synthesis and cell formation; may play a role in

the prevention of neutral tube defects (spina bifida), abortion, abruption placenta

Recommended Nutrient Requirement that increases During Pregnancy

Folic Acid, Folacin, Folate
Requirements 400 mcg/day representing an increase of more then 2 times

the daily prepregnant requirement. 300mcg/day supplement for women with low folate levels or dietary deficiency

4 servings of grains/day

Recommended Nutrient Requirement that increases During Pregnancy

Folic Acid, Folacin, Folate
Food Source Increases should reflect
liver, kidney, lean beef, veal dark green leafy vegetables, broccoli, legumes. Whole grains, peanuts

Recommended Nutrient Requirement that increases During Pregnancy

Additional Requirements
Minerals
Nutrients
Iodine

175 mcg/day 320 mg/day 65 mcg/day

Magnesium

Selenium

Recommended Nutrient Requirement that increases During Pregnancy

Additional Requirements
Minerals
Food Source Increased requirements of pregnancy can easily be met

with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy.

Recommended Nutrient Requirement that increases During Pregnancy

Vitamins E
10 mg/day

Thiamine 1.5 mg/day Riborlavin 1.6 mg/day Pyridoxine ( B6) 2.2 mg/day B12 2.2 mg day Niacin 17 mg/day

Recommended Nutrient Requirement that increases During Pregnancy

Vitamins
Food Source Vit stored in body. Taking it not needed fat soluble

vitamins. Hard to excrete.

Sexual Activity

should be done in moderation should be done in private place mom placed in comfy pos, sidelying or mom on top avoided 6 weeks prior to EDD avoid blowing or air during cunnilingus changes in sexual desire of mom during preg- air embolism

Changes in sexual desire:

1st tri decrease desire due to bodily changes 2nd trimester increased desire due to increase estrogen that

enhances lubrication 3rd trimester decreased desire

Sexual Activity
Contraindication in sex:
1. vaginal spotting
1st trimester threatened abortion 2nd trimester placenta previa

2. incompetent cervix 3. preterm labor 4. premature rupture of membrane

Exercise to strengthen muscles used during delivery process

principles of exercise
Done in moderation. Must be individualized

Walking best exercise Squatting strengthen muscles of perineum. Increase

circulation to perineum. Squat feet flat on floor

Tailor Sitting 1 leg in front of other leg ( Indian seat)

Exercise
Raise buttocks 1st before head to prevent postural hypotension dizziness when changing position
shoulder circling exercise- strengthen chest muscles pelvic rocking/pelvic tilt- exercise relieves low back pain &

maintain good posture * arch back standing or kneeling. Four extremities on floor
Kegel Exercise strengthen pubococcygeal muscles

- as if hold urine, release 10x or muscle contraction

Abdominal Exercise strengthens muscles of abdominal done

as if blowing candle

Childbirth Preparation:
Overall

goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience.

a. Psychophysical

1. Bradley Method Dr. Robert Bradley advocated active

participation of husband at delivery process. Based on imitation of nature.

Features: 1.) darkened rm 2.) quiet environment 3.) relaxation tech 4.) closed eye & appearance of sleep
2. Grantly Dick Read Method fear leads to tension

while tension leads to pain

Childbirth Preparation:
b. Psychosexual 1. Kitzinger method preg, labor & birth & care of newborn is

an impt turning pt in womans life cycle - flow with contraction than struggle with contraction

c. Psychoprophylaxis prevention of pain 1. Lamaze: Dr. Ferdinand Lamaze

req. disciple, conditioning & concentration. Husband is coach Features: Conscious relaxation Cleansing breathe inhale nose, exhale mouth Effleurage gentle circular massage over abdominal to relieve pain imaging sensate focus

Different Methods of delivery:

birthing chair bed convertible to chair semifowlers birthing bed dorsal recumbent pos squatting relives low back pain during labor pain leboyers warm, quiet, dark, comfy room. After delivery,

baby gets warm bath. water, soft music.

Birth under H20 bathtub labor & delivery warm

IX. Intrapartal Notes inside ER

A. Admitting the laboring Mother:
Personal Data: name, age, address, etc Baseline Data: v/s especially BP, weight Obstetrical Data: gravida # preg, para- viable preg, 20

24 wks Physical Exams, Pelvic Exams

 B. Basic knowledge in Intrapartum b. 1 Theories of the Onset of Labor

1.) uterine stretch theory ( any hallow organ stretched, will

always contract & expel its content) contraction action

Hypothalamus produces oxytocin prostaglandin- contraction

2.) oxytocin theory post pit gland releases oxytocin. 3.) prostaglandin theory stimulation of arachidonic acid 4.) progesterone theory before labor, decrease progesterone

will stimulate contractions & labor

5.) theory of aging placenta life span of placenta 42 wks. At

 b. 2 The 4 Ps of labor
1. Passenger a. Fetal head is the largest presenting part common

presenting part of its length.

Bones 6 bones
S sphenoid E ethmoid T temporal

F frontal - sinciput O occuputal - occiput P parietal 2 x

Passenger
Measurement fetal head: transverse diameter 9.25cm biparietal largest transverse bitemporal 8 cm bimastoid 7cm smallest transverse Sutures intermembranous spaces that allow molding.

sagittal suture connects 2 parietal bones ( sagitna) coronal suture connect parietal & frontal bone (crown) lambdoidal suture connects occipital & parietal bone

Passenger
Moldings: the overlapping of the sutures of the skull to permit

passage of the head to the pelvis

Fontanels:

Anterior fontanel bregma, diamond shape, 3 x 4 cm,( > 5

cm hydrocephalus), 12 18 months after birth- close Posterior fontanel or lambda triangular shape, 1 x 1 cm. Closes 2 3 months. Anteroposterior diameter

suboccipitobregmatic 9.5 cm, complete flexion, smallest AP

occipitofrontal 12cm partial flexion occipitomental 13.5 cm hyper submentobragmatic-face presentation extension

 2. Passageway Mom Pelvis

1.) < 49 tall 2.) < 18 years old 3.) Underwent pelvic dislocation

4 main pelvic types 1. Gynecoid round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android heart shape male pelvis- anterior part pointed,

posterior part shallow

3. Anthropoid oval, ape like pelvis, oval shape, AP diameter

wider transverse narrow

4. Platypelloid flat AP diameter narrow, transverse

wider

 b. Pelvis

2 hip bones 2 innominate bones 3 Parts of 2 Innominate Bones

- iliac crest flaring superior border forming prominence of hips

- ischial tuberosity where we sit landmark to get external measurement of pelvis
Pubes ant portion symphisis pubis junction between 2 Ischium - inferior portion

Ileum

- lateral side of hips

pubis

1 sacrum post portion sacral prominence landmark to

get internal measurement of pelvis

Important Measurements
1. Diagonal Conjugate measure between sacral promontory and inferior margin of the symphysis pubis. Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC 11.5 cm=true conjugate) 2. True conjugate/conjugate vera measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm

3. Obstetrical conjugate smallest AP diameter. Pelvis at 10 cm or more.

Tuberoischi Diameter transverse diameter of the pelvic outlet. Ischial tuberosity approximated with use of fist 8 cm & above.

 3. Power the force acting to expel the fetus and placenta

myometrium powers of labor

a. Involuntary Contractions
b. Voluntary bearing down efforts c. Characteristics: wave like d. Timing: frequency, duration, intensity

 4. Psyche/Person psychological stress when the mother

is fighting the labor experience

a. Cultural Interpretation
b. Preparation c. Past Experience d. Support System

 Pre-eminent Signs of Labor

S&Sx:
- shooting pain radiating to the legs - urinary freq.

1. Lightening setting of presenting part into pelvic brim - 2

weeks prior to EDD * Engagement- setting of presenting part into pelvic inlet

2. Braxton Hicks Contractions painless irregular contractions 3. Increase Activity of the Mother- nesting instinct. Save energy,

will be used for delivery. Increase epinephrine

 Pre-eminent Signs of Labor

S&Sx:
4. Ripening of the Cervix butter soft 5. decreased body wt 1.5 3 lbs 6. Bloody Show pinkish vaginal discharge blood &

leukorrhea

7. Rupture of Membranes rupture of water. Check FHT

 Premature Rupture of Membrane ( PROM) - do IE to

check for cord prolapse

Contraction drop in intensity even though very painful Contraction drop in frequently Uterus tense and/or contracting between contractions Abdominal palpations

 Premature Rupture of Membrane ( PROM)

Nursing Care;
Administer Analgesics (Morphine) Attempt manual rotation for ROP or LOP most common

malposition

Bear down with contractions Adequate hydration prepare for CS

Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is

noted

 Cord Prolapse a complication when the umbilical cord

falls or is washed through the cervix into the vagina.

Danger signs: PROM Presenting part has not yet engaged Fetal distress Protruding cord form vagina

 Cord Prolapse

Nursing care: Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy. Slip cord away from presenting part Count pulsation of cord for FHT Prep mom for CS
Positioning trendelenberg or knee chest position Emotional support Prepare for Cesarean Section

 False Labor

Irregular contractions No increase in intensity Pain confined to abdomen Pain relived by walking No cervical changes

True Labor

Contractions are regular Increased intensity Pain begins lower back radiates to abdomen Pain intensified by walking Cervical effacement & dilatation * major sx of true labor.

Duration of Labor
Primipara 14 hrs & not more than 20 hrs Multipara 8 hrs & not > 14 hrs

Effacement softening & thinning of cervix. Use % in unit of

measurement Dilation widening of cervix. Unit used is cm. Nursing Interventions in Each Stage of Labor
2 segments of the uterus 1. upper uterine - fundus 2. lower uterine isthmus

Nursing Interventions in Each Stage of Labor

1. First Stage: onset of true contractions to full dilation and

effacement of cervix.

Latent Phase:
Assessment:
Dilations:

0 3 cm mom excited, apprehensive, can communicate Frequency: every 5 10 min Intensity mild
Encourage walking - shorten 1st stage of labor Encourage to void q 2 3 hrs full bladder inhibit

Nursing Care:

contractions Breathing chest breathing

 Active Phase:
Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self Frequency q 3-5 min lasting for 30 60 seconds Nursing Care: M edications have meds ready A ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc. D dry lips oral care (ointment) dry linens B abdominal breathing

 Transitional Phase:
intensity: strong

hyperesthesia

Mom mood changes with

Assessment:
Dilations Frequency Durations

8 10 cm q 2-3 min contractions 45 90 seconds

 Hyperesthesia increase sensitivity to touch, pain all over

Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain keep informed of progress controlled chest breathing
Nursing Care:

T ires I nform of progress R estless support her breathing technique E ncourage and praise D iscomfort

 Pelvic Exams
Effacement Dilation

a. Station landmark used: ischial spine

- 1 station = presenting part 1cm above ischial spine if (

) floating - 2 station = presenting part 2 cm above ischial spine if (-) floating 0 station = level at ischial spine engagement + 1 station = below 1 cm ischial spine +3 to +5 = crowning occurs at 2nd stage of labor

 b. Presentation/lie
the relationship of the long axis (spine) of the fetus to the

long axis of the mother -spine of mom and spine of fetus

Two types: b.1. Longitudinal Lie ( Parallel)

Cephalic - Vertex complete flexion

Face Brow Chin

Poor Flexion

 Breech - Complete Breech thigh breast on abdomen,

breast lie on thigh

Incomplete Breech thigh rest on abdominal Frank legs extend to head Footling single, double Kneeling
b.2. Transverse Lie (Perpendicular) or Perpendicular lie.

Shoulder presentation.

 c. Position relationship of the fatal presenting part to

specific quadrant of the mothers pelvis.

Variety:
Occipito LOA left occipito ant (most common and

favorable position) side of maternal pelvis LOP left occipito posterior LOP most common mal position, most painful ROP squatting pos on mom ROT ROA

 Breech- use sacrum

anterior - put stet above umbilicus

LSA left sacro

LST, LSP, RSA, RST, RSP]

Shoulder/acromniodorso LADA, LADT, LADP, RADA Chin / Mento LMA, LMT, LMP, RMP, RMA, RMT, RMP

 Monitoring the Contractions and Fetal heart Tone Parts of contractions:

Spread fingers lightly over fundus to monitor contractions

Increment or crescendo beginning of contractions until it

increases

Acme or apex height of contraction Decrement or decrescendo from height of contractions

until it decreases contraction contraction

Duration beginning of contractions to end of same Interval end of 1 contraction to beginning of next

 Contraction vasoconstriction Increase BP, decrease FHT Best time to get BP & FHT just after a contraction or

midway of contractions

Placental reserve 60 sec o2 for fetus during contractions Duration of contractions shouldnt >60 sec Notify MD

 Mom has headache check BP, if same BP, let mom rest. If

BP increase , notify MD preeclampsia

Health teachings
1.) Ok to shower 2.)NPO GIT stops function during labor if with food-

will cause aspiration 3.)Enema administer during labor a.)To cleanse bowel b.)Prevent infection c.)Sims position/side lying 12 18 inch ht enema tubing

 Check FHT after adm enema

Normal FHT= 120-160 Signs of fetal distress 1.) <120 & >160 2.) mecomium stain amnion fluid 3.) fetal thrushing hyperactive fetus due to lack O2

 2. Second Stage: fetal stage, complete dilation and effacement

to birth.

7 8 multi bring to delivery room 10cm primi bring to delivery room Lithotomy pos put legs same time up Bulging of perineum sure to come out Breathing panting ( teach mom) Assist doc in doing episiotomy - to prevent laceration, widen nd

vaginal canal, shorten 2

stage of labor.

 Episiotomy median less bleeding, less pain easy to

repair, fast to heal, possible to reach rectum ( urethroanal fistula) Mediolateral more bleeding & pain, hard to repair, slow to heal

-use local or pudendal anesthesia.

Ironing the perineum to prevent laceration

Modified Ritgens maneuver place towel at perineum 1.)To prevent laceration 2.) Will facilitate complete flexion & extension. (Support

head & remove secretion, check cord if coiled. Pull shoulder down & up.

Check time, identification of baby.

 Mechanisms of labor

Engagement Descent Flexion Internal Rotation Extension External rotation Expulsion

Three parts of Pelvis 1. Inlet AP diameter narrow,

transverse diameter wider 2. Cavity

 Two Major Divisions of Pelvis

True pelvis below the pelvic inlet False pelvis above the pelvic inlet; supports uterus during

pregnancy

Linea Terminales diagonal imaginary line from the sacrum to

the symphysis pubis that divides the false and true pelvis.

Nursing Care:
To prevent puerperal sepsis - < 48 hours only vaginal pack

Bolus of Ptocin can lead to hypotension.

 Third Stage: birth to expulsion of Placenta -placental

stage placenta has 15 28 cotyledons

Placenta delivered from 3-10 minutes

Signs of placental separation

Fundus rises becomes firm & globular Calkins sign Lengthening of the cord Sudden gush of blood

 Types of placental delivery

Shultz

shiny begins to separate from center to edges presenting the fetal side shiny Dunkan dirty begin to separate form edges to center presenting natural side beefy red or dirty
Slowly pull cord and wind to clamp BRANDT ANDREWS

MANEUVER uterus.

Hurrying of placental delivery will lead to inversion of

 Nsg care for placenta:

Check completeness of placenta. Check fundus (if relaxed, massage uterus) Check bp Administer methergine IM (Methylergonovine Maleate) Ergotrate derivatives Monitor hpn (or give oxytocin IV) Check perineum for lacerations Assist MD for episiorapy Flat on bed Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.

 Fourth Stage: the first 1-2 hours after delivery of

placenta recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.

Check placement of fundus at level of umbilicus. If fundus above umbilicus, deviation of fundus
Empty bladder to prevent uterine atony Check lochia

Maternal Observations body system stabilizes Placement of the Fundus Lochia

Perineum R - edness E- dema E - cchemosis D ischarges A approximation of blood loss. Count pad & saturation

Fully soaked pad : 30 40 cc weigh pad. 1 gram=1cc

Bonding interaction between mother and newborn rooming in types

Straight rooming in baby: 24hrs with mom. Partial rooming in: baby in morning , at night nursery

Complications of Labor
Dystocia difficult labor related to:

Mechanical factor due to uterine inertia sluggishness of contraction

hypertonic or primary uterine inertia

intense excessive contractions resulting to ineffective pushing MD administer sedative valium,/diazepam muscle relaxant hypotonic secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin.

 Prolonged labor
normal length of labor in primi 14 20 hrs

Multi 10 -14 hrs

> 14 hrs in multi & > 20 hrs in primi
maternal effect exhaustion. Fetal effect fetal distress,

caput succedaneum or cephal hematoma

nsg care: monitor contractions and FHR

 Precipitate Labor

labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.
Earliest sign: tachycardia & restlessness Late sign: hypotension Outstanding Nursing dx: fluid volume deficit Post of mom modified trendelenberg IV fast drip due fluid volume def
Signs of Hypovolemic Shock:

Hypotension Tachycardia Tachypnea Cold clammy skin

 Inversion of the uterus situation uterus is inside out. MD will push uterus back inside or not hysterectomy.
Factors leading to inversion of uterus

short cord hurrying of placental delivery ineffective fundal pressure

 Uterine Rupture
Causes:
1.)Previous classical CS 2.)Large baby 3.) Improper use of oxytocin (IV drip)

Sx:

sudden pain profuse bleeding hypovolemic shock TAHBSO

 Physiologic retraction ring Boundary bet upper/lower uterine segment BANDLS pathologic ring suprapubic depression a.) sign of impending uterine rupture

 Amniotic Fluid Embolism or placental embolism

amniotic fluid or fragments of placenta enters natural

circulation resulting to embolism

Sx:
dyspnea, chest pain & frothy sputum prepare: suctioning

end stage: DIC disseminated intravascular coagopathybleeding to all portions of the body eyes, nose, etc.

Trial Labor measurement of head & pelvis falls on borderline.

Mom given 6 hrs of labor

Multi: 8 14, primi 14 20

 Preterm Labor labor after 20 37 weeks) ( abortion <20

weeks)

Sx:
1. premature contractions q 10 min 2. effacement of 60 80% 3. dilation 2-3 cm

Home Mgt: 1. complete bed rest 2. avoid sex 3. empty bladder 4. drink 3 -4 glasses of water full bladder inhibits contractions 5. consult MD if symptoms persist

 Hosp:
1. If cervix is closed 2 3 cm,

administer Tocolytic agentscontractions.YUTOPAR- Yutopar Hcl) 150mg incorporated 500cc Dextrose piggyback. Monitor: FHT > 180 bpm Maternal BP - <90/60 Crackles notify MD pulmo edema administer oral yutopar 30 minutes before d/c IV Tocolytic (Phil) Terbuthaline (Bricanyl or Brethine) sustained tachycardia Antidote propranolol or inderal - beta-blocker

dilation saved by halts preterm

 If cervix is open MD
steroid dextamethzone (betamethazone) to facilitate

surfactant maturation preventing RDS

Preterm-cut cord ASAP to prevent jaundice or

hyperbilirubenia.

 X. Postpartal Period 5th stage of labor

after 24hrs :Normal increase WBC up to 30,000 cumm

Puerperium covers 1st 6 wks post partum Involution return of repro organ to its non pregnant

state.

Hyperfibrinogenia
- prone to thrombus formation - early ambulation

 Principles underlying puerperium

1. To return to Normal and Facilitate healing

A. Physiologic Changes
a.1. Systemic Changes

1. Cardiovascular System
- the first few minutes after delivery is the most critical

period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers.

 2. Genital tract
a. Cervix cervical opening b. Vaginal and Pelvic Floor c. Uterus return to normal 6 8 wks. Fundus goes down 1

finger breath/day until 10th day no longer palpable due behind symphisis pubis

3 days after post partum: sub involuted uterus delayed healing

uterus with big clots of blood- a medium for bacterial growth(puerperal sepsis)- D&C
1. position prone 2. cold compress to prevent bleeding 3. mefenamic acid

after, birth pain:

 d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs

with lochia.

1. Ruba red 1st 3 days present, musty/mousy, moderate

amt 2. Serosa pink to brown 4 9th day, limited amt 3. Alba crme white 10 21 days very decreased amt
dysuria
- urine collection - alternate warm & cold compress - stimulate bladder

 3. Urinary tract:
Bladder freq in urination after delivery- urinary

retention with overflow

4. Colon:
Constipation due NPO, fear of bearing down

5. Perineal area painful episiotomy site sims pos, cold

compress for immediate pain after 24 hrs, hot sitz bath, not compress
sex- when perineum has healed

II. Provide Emotional Support Reva Rubia

Psychological Responses: Taking in phase
dependent phase (1st three days) mom passive, cant

make decisions, experiences.

activity is to tell

child

birth

Nursing Care: - proper hygiene

 Taking hold phase

dependent to independent phase (4 to 7 days). Mom is

active, can make decisions

HT:
Care of newborn Insert family planting method common post partum blues/ baby blues present 4 5

days 50-80% moms overwhelming feeling of depression characterized by crying, despondenceinability to sleep & lack of appetite. let mom cry therapeutic.

Letting go
interdependent phase 7 days & above. Mom

redefines new roles may extend until child grows.

III. Prevent complications

Hemorrhage bleeding of > 500cc

CS 600 800 cc normal NSD 500 cc

Early postpartum hemorrhage bleeding within 1st 24 hrs.

Baggy or relaxed uterus & profuse bleeding uterine atony. Complications: hypovolemic shock.

 Mgt:

massage uterus until contracted cold compress modified trendelenberg IV fast drip/ oxytocin IV drip

1st degree laceration affects vaginal skin & mucus

membrane. 2nd degree 1st degree + muscles of vagina 3rd degree 2nd degree + external sphincter of rectum 4th degree 3rd degree + mucus membrane of rectum

 Breast feeding post pit gland will release oxytocin so

uterus will contract.

Well contracted uterus + bleeding = laceration assess perineum for laceration degree of laceration mgt episiorapy

 DIC
Disseminated Intravascular Coagulopathy.

Hypofibrinogen- failure to coagulate.

bleeding to any part of body hysterectomy if with abruption placenta

mgt:
BT- cryoprecipitate or fresh frozen plasma

 Late Postpartum hemorrhage

bleeding after 24 hrs retained placental fragments

Mgt:
D&C or manual extraction of fragments & massaging of

uterus. D&C except placenta increta, percreta,

Acreta attached placenta to myometrium. Increta deeper attachment of placenta to myometrium

hysterectomy

Percreta invasion of placenta to perimetrium

 Hematoma bluish or purple discoloration of SQ tissue of vagina or

perineum.

too much manipulation large baby pudendal anesthesia

Mgt:

cold compress every 30 minutes with rest period of 30 minutes for 24 hrs shave incision on site, scraping & suturing

Infection- sources of infection

1.)endogenous from within body 2.) exogenous from outside

anaerobic streptococci most common - from members health

team unhealthy sexual practices

General signs of inflammation: Inflammation calor (heat), rubor (red), dolor (pain) tumor(swelling) purulent discharges fever

 Gen mgt:
1.)

supportive care CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity for antibiotic

prolonged use of antibiotic lead to fungal infection inflammation of perineum see general signs of

inflammation

2 to 3 stitches dislocated with purulent discharge

 Mgt:
Removal of sutures & drainage, saline, between &

resulting. Endometriosis inflammation of endometrial lining

Sx:

Abdominal tenderness, pos. Fowlers to facilitate drainage & localize infection

oxytocin & antibiotic

 IV. Motivate the use of Family Planning

determine ones own beliefs 1st never advice a permanent method of planning method of choice is an individuals choice.

Natural Method the only method accepted by the Catholic

Church

Billings / Cervical mucus test spinnbarkeit & ferning

(estrogen) clear, watery, stretchable, elastic long spinnbarkeit ovulation no sex get before arising in bed

Basal Body Temperature

13th day temp goes down before

 LAM lactation amenorrheal method hormone that inhibits

ovulation is prolactin. breast feeding- menstruation will come out 4 6 months bottle fed 2 3 months disadvantage of lam might get pregnant

Symptothermal combination of BBT & cervical. Best method Social Method 1.) coitus interuptus/ withdrawal

effective method coitus reservatus sex without ejaculation coitus interfemora ipit calendar method

- least

 OVULATION count minus 14 days before next mens (14 days

before next mens)

Origoknause formula monitor cycle for 1 year -get short test & longest cycle from Jan Dec shortest 18 longest 11

June 26 - 18 8

Dec 33 -11 22 unsafe days

21 day pill- start 5th day of mens 28day pill- start 1st day of mens missed 1 pill take 2 next day

Physiologic Method
Pills combined oral contraceptives prevent ovulation by

inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to become pregnant- 3 months. Consult OB-6mos.

Alerts on Oral Contraceptive:

-in case a mother who is taking an oral contraceptive for

almost long time plans to have a baby, she would wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal.

Alerts on Oral Contraceptive:

- 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. headache as this is an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage.

- discontinue oral contraceptive if there is signs of severe

Signs of hypertension
Immediate Discontinuation

A abdominal pain C chest pain H - headache E eye problems S severe leg cramps
If mom HPN stop pills STAT!
Adverse effect: breakthrough bleeding

 Contraindicated:

chain smoker extreme obesity HPN DM Thrombophlebitis or problems in clotting factors

if forgotten for one day, immediately take the forgotten

tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again.

 DMPA depoproveda has progesterone inhibits LH

inhibits ovulation Depomedroxy progesterone acetate IM q 3 months

- never massage injected site, it will shorten duration

Norplant has 6 match sticks like capsules implanted

subdermally containing progesterone.

5 yrs disadvantage if keloid skin as soon as removed can become pregnant

 Mechanism and Chemical Barriers

Intrauterine Device (IUD)

Action: prevents implantation affects motility of sperm &

ovum

right time to insert is after delivery or during menstruation

primary indication for use of IUD

parity or # of children, if 1 kid only dont use IUD

HT:

Check for string daily Monthly checkup Regular pap smear

 Alerts

prevents implantation most common complications: excessive menstrual flow and

expulsion of the device (common problem) others:

P eriod late (pregnancy suspected) Abnormal spotting or bleeding

A bdominal pain or pain with intercourse I nfection (abnormal vaginal discharge) N ot feeling well, fever, chills S trings lost, shorter or longer Uterine inflammation, uterine perforation, ectopic

pregnancy

 Condom latex inserted to erected penis or lubricated

vagina Adv; gives highest protection against STD female condom

Alerts: Disadvantage:
it lessen sexual satisfaction it gives higher protection in the prevention of STDs

 Diaphragm rubberized dome shaped material inserted to

cervix preventing sperm to get to the uterus. REVERSiBLE

Ht:

proper hygiene check for holes before use must stay in place 6 8 hrs after sex must be refitted especially if without wt change 15 lbs spermicide chem. Barrier ex. Foam (most effective), jellies, creams

S/effect: Toxic shock syndrome Alerts: Should be kept in place for about 6 8 hours

 Cervical Cap most durable than diaphragm no need to

apply spermicide C/I: abnormal pap smear

Foams, Jellies, Creams Surgical Method BTL , Bilateral Tubal Ligation can be

reversed 20% chance. HT: avoid lifting heavy objects

Vasectomy cut vas deferense. HT: >30 ejaculations before safe sex O zero sperm count, safe

XI. High Risk Pregnancy

Hemorrhagic Disorders

General Management CBR Avoid sex Assess for bleeding (per pad 30 40cc) (wt 1gm =1cc) Ultrasound to determine integrity of sac Signs of Hypovolemic shock Save discharges for histopathology to determine if product of conception has been expelled or not

 First Trimester Bleeding abortion or eptopic A. Abortions termination of pregnancy before age of

viability (before 20 weeks)

Spontaneous Abortion- miscarriage

Cause:
1.) chromosomal alterations 2.) blighted ovum 3.) plasma germ defect

 Classifications: Threatened pregnancy is jeopardized by bleeding and

cramping but the cervix is closed Inevitable moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
Types:
Complete all products of conception are expelled. No mgt

just emotional support! Incomplete Placental and membranes retained. Mgt: D&C Incompetent cervix abortion
McDonalds procedure temporary circlage on cervix

S/E; infection. During delivery, circlage is removed. NSD Sheridan permanent surgery cervix. CS

 c.

Habitual 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2nd trimester
Missed fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction

d.

5.)

Induced Abortion therapeutic abortion to save life of mom. Double effect choose between lesser evil.

 Ectopic Pregnancy occurs when gestation is located outside

the uterine cavity. common site: tubal or ampular Dangerous site interstitial
Unruptured

missed period abdominal pain within 3 -5 weeks of missed period (maybe

generalized or one sided) scant, dark brown, vaginal bleeding

Nursing care: Vital signs Administer IV fluids Monitor for vaginal bleeding Monitor I & O

 Tubal Rupture

sudden , sharp, severe pain. Unilateral radiating to shoulder.

shoulder pain (indicative of intraperitoneal bleeding that

extends to diaphragm and phrenic nerve) peritoneal bleeding

+ Cullens Sign bluish tinged umbilicus signifies intra syncope (fainting) Mgt:
Surgery depending on side Ovary: oophrectomy Uterus : hysterectomy

 Second trimester bleeding

C. Hydatidiform Mole bunch or grapes or gestational

trophoblastic disease. with fertilization. Progressive degeneration of chorionic villi. Recurs.

- gestational anomaly of the placenta consisting of a

bunch of clear vesicles. This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.

 Use: methotrexate to prevent choriocarcinoma Assessment: Early signs -

vesicles passed thru the vagina Hyperemesis gravidarium increase HCG Fundal height

Vaginal bleeding( scant or profuse) Early in pregnancy

High levels of HCG Preeclampsia at about 12 weeks

 Late signs

hypertension before 20th week Vesicles look like a snowstorm on sonogram Anemia Abdominal cramping hyperthyroidism Pulmonary embolus

Serious complications

Nursing care:

Prepare D&C Do not give oxytoxic drugs Teachings:

Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma Avoid pregnancy for at least one year

Third Trimester Bleeding Placenta Anomalies

Placenta Previa it occurs when the placenta is improperly

implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta. candidate for CS
Bright red Painless bleeding

Sx: frank

Dx:

Ultrasound Avoid: sex, IE, enema may lead to sudden fetal blood loss Double set up: delivery room may be converted to OR

 Assessment:
Engagement (usually has not occurred) Fetal distress Presentation ( usually abnormal)

Surgeon in charge of sign consent, RN as witness MD explain to patient complication: sudden fetal blood loss Nursing Care

NPO Bed rest Prepare to induce labor if cervix is ripe Administer IV

 Abruptio Placenta it is the premature separation of the

placenta form the implantation site. It usually occurs after the twentieth week of pregnancy.

Outstanding Sx: dark red, painful bleeding, board like or

rigid uterus.

Assessment:
Concealed bleeding (retroplacental) Couvelaire uterus (caused by bleeding

into the myometrium)-inability of uterus to contract due to hemorrhage. Severe abdominal pain Dropping coagulation factor (a potential for DIC)

 Complications:
Sudden fetal blood loss -placenta previa & vasa previa

Nursing Care:

Infuse IV, prepare to administer blood Type and crossmatch Monitor FHR Insert Foley Measure blood loss; count pads Report s/sx of DIC Monitor v/s for shock Strict I&O

 Placenta succenturiata 1 or 2 more lobes connected to the

placenta by a blood vessel may lead to retained placental fragments if vessel is cut. Placenta Circumvalata fetal side of placenta covered by chorion Placenta Marginata fold side of chorion reaches just to the edge of placenta Battledore Placenta cord inserted marginally rather then centrally Placenta Bipartita placenta divides into 2 lobes Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta Vasa Previa velamentous insertion of cord has implanted in cervical OS

Hypertensive Disorders

I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.

Gestational hypertension - HPN without edema & protenuria H without EP Pre-eclampsia HPN with edema & protenuria or albuminuria HE P/A HELLP syndrome hemolysis with elevated liver enzymes & low platelet count

 II. Transissional Hypertension HPN between 20 24

weeks

III. Chronic or pre-existing Hypertension HPN before 20

weeks not solved 6 weeks post partum.

Three types of pre-eclampsia 1.) Mild preeclampsia earliest sign of preeclampsia

a.) increase wt due to edema b.) BP 140/90 c.) protenuria +1 - +2

 2.) Severe preeclampsia

Signs present: cerebral and visual disturbances, epigastric

pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110 , protenuria +3 - +4

3.) Eclampsia with seizure! Increase BUN glomerular

damage. Provide safety.

Cause of preeclampsia
idiopathic or unknown common in primi due to 1st exposure

to chorionic villi common in multiple pre (twins) increase exposure to chorionic villi common to mom with low socioeconomic status due to decrease intake of CHON

 Nursing care:

P romote bed rest to decrease O2 demand, facilitate,

sodium excretion, water immersion will cause to urinate. P- prevent convulsions by nursing measures or seizure precaution 1.) dimly lit room . quiet calm environment 2.) minimal handling planning procedure 3.) avoid jarring bed
P- prepare the following at bedside

- tongue depressor - turning to side done AFTER seizure! Observe only! for safely. E ensure high protein intake ( 1g/kg/day) - Na in moderation

 A anti-hypertensive drug Hydralazine ( Apresoline) C convulsion, prevent Mg So4 CNS depressant E valuate physical parameters for Magnesium sulfate

Magnesium SO4 Toxicity: BP decrease Urine output decrease Resp < 12 Patella reflex absent 1st sigh Mg SO4 toxicity. antidote Ca gluconate

 3.Diabetes Mellitus - absence of insufficient insulin (Islet

of Langerhans of pancreas)

Function: of insulin facilitates transport of glucose to cell Dx: 1 hr 50gr glucose tolerance test GTT Normal glucose 80 120 mg/dl

hypoclycemic

<

80

( euglycemia)
3 degrees GTT of > 130 mg/dL

> 120 - hyperglycemia

 maternal effect DM
Hypo or hyperglycemia 1st trimester hypo, 2nd 3rd

trim hyperglycemic Frequent infection- moniliasis Polyhydramnios Dystocia-difficult birth due to abnormalities in fetus or mom. Insulin requirement, decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd 3rd trimester. Post partum decrease 25% due placenta out.

 Fetal effect
hyper & hypoglycemia macrosomia large gestational age baby delivered >

400g or 4kg preterm birth to prevent stillbirth

Newborn Effect : DM
hyperinsulinism hypoglycemia

normal glucose in newborn 45 55 mg/dL hypoglycemic < 40 mg/dL Heel stick test get blood at heel

 Sx:

Hypoglycemia high pitch shrill cry tremors, administer

dextrose hypocalcemia - < 7mg%

Sx:

Calcemia tetany Trousseau sign Give calcium gluconate if decrease calcium Therapeutic abortion If push through with pregnancy

Recommendation

antibiotic therapy- to prevent sub acute bacterial endocarditis anticoagulant heparin doesnt cross placenta

 Class I & II- good progress for vaginal delivery Class III & IV- poor prognosis, for vaginal delivery, not CS! NOT lithotomy! High semi-fowlers during delivery. No

valsalva maneuver

Regional anesthesia! Low forcep delivery due to inability to push. It will shorten

2nd stage of labor

 Heart disease
Moms with RHD at childhood Class I no limit to physical activity Class II slight limitation of activity. Ordinary activity

causes fatigue & discomfort.

Recommendation of class I & II

sleep 10 hrs a day rest 30 minutes & after meal

 Class III - moderate limitation of physical activity.

Ordinary activity causes discomfort

Recommendation:
1.) early hospitalization by 7 months

Class IV. marked limitation of physical activity. Even at rest

there is fatigue & discomfort.

Recommendation:
Therapeutic abortion

XII. Intrapartal complications

Cesarean Delivery Indications:

Multiple gestation Diabetes Active herpes II Severe toxemia Placenta previa Abruptio placenta Prolapse of the cord CPD primary indication Breech presentation Transverse lie

 Procedure:
classical vertical insertion. Once classical always classical Low segment bikini line type aesthetic use

VBAC vaginal birth after CS

INFERTILITY - inability to achieve pregnancy. Within a year of

attempting it Manageable

STERILITY - irreversible Impotency inability to have an erection

 2 types of infertility

1.) primary no pregnancy at all 2.) Secondary 1st pregnancy, no more next preg

test male 1st

more practical & less complicated need: sperm only sterile bottle container ( not plastic has chem.) Sims Huhner test or post coital test. Procedure: sex 2 hours before test mom remains supine 15 min after ejaculation

Normal: cervical mucus must be stretchable 8 10 cm with 15

20 sperm. If >15 low sperm count

Best criteria- sperm motility for impotency

 Factors: low sperm count

occupation- truck driver chain smoker

administer: clomid ( chomephine citrate) to induce

spermatogenesis count

Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm Implant sperm in ampula

 1.) Mom: anovulation no ovulation. Due to increase prolactin

hyperprolactinemia

Administer; parlodel ( Bromocryptice Mesylate) Action; antihyper prolactineuria Give mom clomid: action: to induce oogenesis or ovulation S/E: multiple pregnancy scarred tubes

2.) Tubal Occlusion tubal blockage Hx of PID that has

use of IUD appendicitis (burst) & scarring = dx: hysterosalphingography used to determine tubal

patency with use of radiopaque material

 Mgt: IVF invitrofertilization (test tube baby) England 1st test tube baby

To shorten 2nd stage of labor!

fundal pressure episiotomy forcep delivery