Handouts Obstetric Nursing

Maternal and Child Nursing THE FEMALE REPRODUCTIVE SYSTEM I. External Genitalia a. Mons pubis b. Labia majora  Nulliparous:  multiparous: c. Labia minora d. Clitoris  Sensitive to touch & temperature  2 erectile tissue: corpus cavernosa  Sexual intercourse:  Clitoral congestion & erection  Produce cheese-like secretion: e. Vestibule a. b. c. d. e. II. Internal Genitalia a. Vagina  8-12 cm long  Before puberty  After puberty b. Uterus  Organ of:  Layers:  Parts:  2.5-3 inches long  2 inches wide  50-70 gms  Supporting ligaments: 1. Broad 2. Round 3. Posterior c. Fallopian Tube Parts:  Interstitial  Isthmus  Ampulla  Infundibulum d. Ovaries 6-19 gms, 1.5-3cm wide, 2-5 cm long 1

Maria Nazarethe A. Sulit| ©2009

Maternal and Child Nursing III.

Accessory Structures a. Mammary glands S-

W-

D-

 Parts: o Acini cells o Lactiferous duct o Lactiferous sinus  Dilated portion behind the nipple  Reservoir of milk o Nipples o Areola  Montgomery tubercles  Hormones o Estrogen  Stimulates dev’t of the ductile structures of the breast o Progesterone  Stimulates the dev’t of acinar structures of the breast o Human Placental Lactogen  Promotes breast dev’t during pregnancy o Prolactin  Stimulates milk production  inhibited by estrogen o Oxytocin  Let down reflex  inhibited by progesterone THE MALE REPRODUCTIVE SYSTEM I. External Genitalia a. Penis b. Scrotum II. Internal Genitalia a. Testes  Descends in the scrotum at 28 week gestation  4-5 cm long  Parts o Seminiferous tubules  where spermatogenesis takes place o Leydig’s/ interstitial cells  Found around the semineferous tubules o Sertoli cells b. Epididymis  Appx 20 feet long  Passageway for the traveling sperm for 12-20 days 2

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Maternal and Child Nursing c. Vas deferens  Passageway of the sperm from the epdidymis in the testes to the urethra d. Ejaculatory duct The Process of Spermatogenesis Testes  epididymis  Vas Deferens  Seminal Vesicle (secreted: fructose form of glucose, nutritative value)  Ejaculatory Duct  Prostate Gland  Cowpers Gland  Urethra

III. Accessory structures a. Seminal vesicles b. Prostate gland c. Bulbourethral gland The Analogous Male

Female

Spermatozoa Glans clitoris Scrotum Vagina Testes Fallopian tube Prostate gland Bartholin’s gland 3

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Maternal and Child Nursing THE EVOLUTION OF LIFE I. Prefertilization a. Ovum moves to the ampulla by means of peristaltic movement b. Sperm moves into the ampulla by means of their tail c. Before sperm can penetrate the ovum, the cap must be removed Capacitation- physiologic removal of the acrosome d. Acrosome reactionHyaluronidase- proteolytic enzyme released Zona pellucid-protective covering of the ovum Corona radiate-cells that encircle the zona pellucida II. Conception/Fertilization Zona reaction- ovum becomes impenetrable to other sperms  Zygote  Blastomere  Morula  Blastocyst  Embryo  Fetus III. Implantation  Trophoblast o Placenta     o Fetal membrane o Umbilical cord o Amniotic fluid  Embryoblast o Germ Layers  Ectoderm  mucus membrane, acessories, nervous system  Entoderm  bladder, GIT, tonsils, thyroid gland, respiratory system  Mesoderm  kidneys, musculoskeletal, reproductive, cardiovascular  Embryonic Membrane a. Chorion - Outer membrane b. Amnion - Inner membrane c. Amniotic fluid  Slightly yellow d. Placenta  Contains 30 separate (cotyledons) 4

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Maternal and Child Nursing

IV.

2 Functions: a. Metabolic exchange  produces nutrients needed by the embryo  systhesis of glycogen, cholesterol & fatty acids b. Endocrine Function  HCG  HPL o Human chorionic somatomammotropin o Promotes normal nutrition & growth of the fetus  Estrogen  Progesterone e. Umbilical cord Fetal Development 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months

ANTEPARTUM I. Schedule of Visits

II.    III. 



Classification of Pregnancy Gravida Para TPALM Determination of Pregnancy Presumptive Sign o Amenorrhea o Breast changes o Skin changes o Quickening o Chadwick’s Sign Probable Sign o Goodell o Hegar o Piskacek 5

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Maternal and Child Nursing  Positive Sign o o o IV. Physiologic Changes of Pregnancy a.Breast  Increase in size & nodularity  Enlarged Montgomery’s tubercles  Veins become prominent  Colostrum b. Uterus  Increase in vascularity  Presence of Hegar’s sign c. Cervix  Formation of mucus plug or operculum  Presence of Goodell’s sign d. Vagina e. Gastrointestinal system  Constipation  Heartburn  Hemorrhoids  Morning sickiness f. Urinary system g.Musculoskeletal system h. Intergumentary system  Chloasma  Linea nigra  Striae gravidarum i. Endocrine system  Increase activity & hormone production V. Antepartum Assessment a. Nagele’s Rule

b. Fundal Height

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Maternal and Child Nursing c. Leopold’s Maneuver     VI. Evaluation of Fetal Well Being  Fundic Souffle o Caused by blood rushing through the umbilical arteries. Synchronous with the FHR.  Uterine Souffle o Caused by the sound of blood passing through the uterine vessels. Synchronous with the maternal pulse.  Amniocentesis o TEST RESULTS: within 2-4 weeks o Complication: Premature labor, Infection, Rh isoimmunization  Electronic Fetal Heart Rate Monitoring a. NST o Tocodynamometer records fetal movements and Doppler ultrasound measures fetal heart rate to assess fetal well-being after 28 weeks. o 2 or more FHR accelerations of 15 seconds over a 20 minute interval, and return of FHR to normal baseline. b. Contraction Stress Test o Late decelerations with at least 50% of contractions o No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in 10 minute period.  Fetal Activity o Daily recording of fetal movements o 3 or more movements felt in 1 hour VII. Psychosocial Adaptation to Pregnancy a. 1st Trimester o acceptance of the biological fact of pregnancy b. 2nd Trimester o acceptance of the fetus as a distinct individual and a person to care for c. 3rd Trimester o prepare realistically for the birth and parenting of the child INTRAPARTUM I. Theories of Labor a. Uterine Stretch Theory b. Oxytocin Theory c. Progesterone Deprivation Theory d. Prostaglandin Theory e. Theory of the Aging Placenta 7

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Maternal and Child Nursing II.

Factors Affecting Labor A. Passageway o Diagonal Conjugate- from lower border of symphysis pubis to sacral promontory o Obstetric conjugate- distance between inner surface of symphysis pubis & sacral promontory o True conjugate or conjugate vera o Tuber-ischial diameter/ Intertuberous diameter- measures the outlet between the inner borders of ischial tuberosities  Pelvic Divisions o False o True- Consists of the pelvic inlet, pelvic cavity, and pelvic outlet o Linea Terminalis

 Types of Pelvis  Android  Anthropoid  Gynecoid  Platypelloid

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Maternal and Child Nursing B. Passenger a. Fetal Attitude b. Fetal Presentation c. Fetal Lie d. Fetal Positions C. Power- refers to the frequency, duration, and strength of uterine contractions to cause complete cervical effacement and dilation D. Placental factors E. Psyche III. Premonitory Signs of Labor a. Lightening b. Cervical changes  Effacement  Dilation c. Regular Braxton Hick’s Contraction d. Rupture of amniotic membrane e. Nestling behaviors f. Weight loss IV. True vs False Labor True Labor False Labor Regular contractions Decrease in frequency & intensity Shorter intervals bet. contractions Activity such as walking either has no effect or decreases contraction Disappear while sleeping

V.

Activity such as walking, increases contractions

No appreciable change in the cervix Labor Contractions

VI. Fetal Monitoring  Variability o Irregular fluctuations in the baseline of FHR of 2 cycles per minute or greater  Accelerations o 15 bpm rise above baseline followed by a return to baseline 9

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Maternal and Child Nursing  Decelerationso Fall below baseline lasting 15 seconds or more followed by a return to baseline a. Type 1    b. Type 2    c. Type 3    VII. Labor a. Stage 1 Latent Active Transition Time

Cervix

Contraction

Intensity

Manifestations

b. Stage 2  Cardinal Movement of Labor (Even Donna Failed In Easy English Exam)

c. Stage 3

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Maternal and Child Nursing d. Stage 4

VIII.

APGAR A P G A R

POSTPARTUM I. Uterine involution II. Lochia a. Rubra b. Serosa c. Alba III. Post Partum Psychosocial Adaptation a. Taking In b. Taking Hold c. Letting Go TERATOGENS – any drug or irradiation, the exposure to which may cause damage to the fetus

a. b. c. d. e. f. g.

Streptomycin/Anti – TB – Tetracycline Vitamin K – Iodides – Thalidomides – Steroids – Lithium – Substances

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Effects to Fetus

a. Alcohol

LBW

b. Cigarette

LBW

c. Caffeine

LBW

d. Cocaine

LBW

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Maternal and Child Nursing TORCH – group of infections that can cross the placenta or ascend through the birth canal and adversely affect fetal growth

TORCHANTEPARTUM COMPLICATIONS I. Ectopic Pregnancy Causes: a. b. c. Assessment Findings: Complications:  Hemorrhage/shock  Peritonitis Diagnostics:  Culdocentesis  Ultrasound Management: II.

Abortion

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Maternal and Child Nursing Causes: a. b. c. Assessment Findings:

Management:

III.

Hydatidiform Mole Types: a. Complete b. Partial Assessment Findings:

Management: IV.

Incompetent Cervix Assessment Findings: Management:

V.

Hyperemesis Gravidarum

VI.

Anemia

VII.

Placenta Previa Perdisposong Factors:       Assessment Findings:

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Maria Nazarethe A. Sulit| ©2009

Maternal and Child Nursing

VIII.

Abruptio Placenta Risk Factors:  Uterine anomalies  Multiparity  Trauma to the abdomen  Previous 3rd trimester bleeding  Abnormally large placenta Types:    Assessment Findings:

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CHARACTERISTCS

ABRUPTIO PLACENTA

PLACENTA PREVIA

Onset Bleeding Pain & Uterine Tenderness FHR Presenting Part Shock Delivery

3rd Trimester

3rd Trimester

Moderate to severe Immediate delivery, usually by CS

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Usually not present Delivery maybe delayed,

Maternal and Child Nursing IX.

Pregnancy Induced Hypertension Incidence:  Severe nutritional deficiencies  < 15 years or > 35 years of age     

Common Types:  Gestational HTN

 Preeclampsia

 Eclampsia

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Maternal and Child Nursing

Assessment Findings: a) Mild Pre-Eclampsia  Increase systole > 30 mmhg (3 measurements)  Increase diastolic 15 mmhg b) Severe Pre-Eclampsia  >160/110 mmhg or higher (2 occasions)  Proteinuria 3-4+ c) Eclampsia  Presence of convulsions  Coma Management:

     

Hydralazie (Apresoline) Magnesium sulfate Magnesium sulfate Diazepam Phenobarbital Phenytoin

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Maria Nazarethe A. Sulit| ©2009

Maternal and Child Nursing X.

Gestational Diabetes Mellitus

Assessment Findings:

Diagnostics:  FBS  HbA 1cv  Oral Glucose Tolerance Test Management:

XI.

RH Incompatibility

Management:  Blood test early pregnancy 

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Maternal and Child Nursing XII.

Multiple Gestation Types:  Monozygotic Twins

 Dizygotic Twins

Assessment Findings:  Uterine size is greater than expected  Palpation of three or more large parts  Different FHT Complications:  Fetal malpresentation  Uterine dysfunction due to over stretching  Twin to twin transfusion Management:  Prenatal care  Balanced diet  Rest periods  Anticipatory guidance & support

INTRAPARTUM COMPLICATIONS I. Premature Rupture of Membranes Amniotic fluid gushing from the vagina in the absence of contraction Contributing Factors:  Amniotic sac with weak structure  Recent sexual intercourse Diagnostics:  Nitrazine test tape Management:  Monitored : infection / spontaneous labor  Bed rest

 Tocolytic therapy  Betamethasone (Celestone) II. Cord Prolapse 18

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Maternal and Child Nursing Etiology:  Rupture of membranes with the fetal presenting part unengaged  Hydramios Assessment Findings:  Cord protruding from the vagina  Cord palpated in the vagina or cervix  Fetal distress Management:  O2 therapy  Push presenting part forward  Deliver ASAP III. Preterm Labor Etiology:  Incompetent cervix  Placenta previa/Abruptio placenta  Previous preterm labor Management:  Tocolytic therapy not needed if contractions stops  Fetal and uterine contraction monitoring

     

Ritodrine HCl (Yutopar) Terbutaline sulfate (Brethine) Magnesium Sulfate NSAIDS Indomethacin (Indocin) Betamethasone

IV. Post Term Labor Assessment Findings:  Weight loss and decreased uterine size Management:  Provide emotional and physical support V. Induction of Labor a. Amniotomy - Initiated when the cervix is soft, partially effaced, slightly dilated, presenting part is engaged b. Prostaglandin 19

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Maternal and Child Nursing - 8-12 hours after Prostaglandin E2 administration, pump infusion of Oxytocin (Pitocin) c. Oxytocin

 Dinoprostone (Prepidil)  Prostin E2 suppository or gel  OXYTOCIN (Pitocin, Syntocinon) VI. Precipitate Labor Complications: a. mother b. infant Management: - Support and guide fetal head through birth canal when birth occurs VII. Uterine Rupture Causes:  Rupture of the scar from a previous CS  Forceps delivery  Use of oxytocin  Fundal push Management:  IVF  maintain patent airway VIII.

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Episiotomy

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Maternal and Child Nursing Assessment Findings: REEDAManagement:  Apply ice packs to perineal area for the first 12-24 hours after delivery.  Sitz bath with either warm or cool water IX. Lacerations  1st Degree  2nd Degree  3rd Degree  4th Degree X. Forceps Delivery Purpose:  Prevents excessive pounding of the fetal head against the perineum  Prevents exhaustion from a woman’s pushing effect Assessment Findings:  Cervix fully dilated before use of forceps  Fetus in vertex presentation  Bowel and bladder empty XI. Cesarean Section

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Maternal and Child Nursing Types: a. Classical Advantage  Simple and rapid to perform  Disadvantage  Potential for rupture of the scar with subsequent pregnancy  b. Pfannenstiel’s incision Advantages  Less chance of rupture of uterine scar during future deliveries  Fewer postpartum complications Disadvantages  Longer to perform than classic incision XII. Uterine Inversion Types: a.Forced Inversion Cause : excessive pulling of the cord , vigorous manual expression of the placenta or clots from an atonic uterus b. Spontaneous Inversion Cause: due to increased abdominal pressure from bearing down, coughing, or sudden abdominal muscle contraction Predisposing Factors:  Straining after delivery of the placenta  Vigorous kneading of the fundus to expel the placenta  Manual separation and extraction of the placenta Assessment Findings:  Extrusion of the inner uterine lining into the vagina Management:  Restore the uterus to its normal position  use of general anesthesia and tocolytic therapy POSTPARTUM COMPLICATIONS I. Post Partum Hemorrhage

Management:  Monitor BP and PR Q5-15 minutes  Prepared for a possible D&C  IV infusion, oxytocin, and BT

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Maternal and Child Nursing

 Oxytoxic methylergonovine maleate (Methergine) II.

Subinvolution Delayed return of the enlarged uterus to normal size and function Assessment Findings:  Larger than normal uterus  Prolonged lochial discharge Management:  Massage uterus, facilitate voiding  Administer prescribed medications

III.

Puerperal Infection

IV.

Mastitis Inflammation of the breast tissue caused by infection or stasis of milk in the ducts Management:  Administer antibiotics  Breast feed frequently

V.

Post Partum Mood Disorders  Postpartum Blues  Postpartum Depression  Postpartum Psychosis

FAMILY PLANNING Natural Method  

Abstinence Coitus interruptus (withdrawal) 80% effective with typical use



Rhythm (Calendar method) Ovulation occurs 14 days (plus or minus 2 days) prior to next menses sperm viable for 5 days ovum is capable of being fertilized for 24 hours fertile period = shortest cycle minus 18 days and longest cycle minus 11 days 91% effective with perfect use; 75% effective with typical use 23

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Maternal and Child Nursing 

Basal body temperature (BBT) Temperature drops just prior to ovulation, rises and fluctuates at higher level until 2-4 days prior to next menses basal thermometer – shows tenths of a degree get temperature each AM prior to getting out of bed avoid intercourse on the day temperature drops and for 3 days thereafter 97% effective with perfect use; 75% effective with typical use



Cervical Mucus method (Billing’s, Ovulation) Luteal Phase - infertile period - dominant hormone: progesterone - vaginal characteristics:dry - cervical mucus characteristics:  scant  cloudy, white to yellow  beading – on microscope Follicular phase – ovulation - fertile period - dominant hormone: estrogen - vaginal characteristics: wet - cervical mucus characteristics:  profuse, clear  thin, watery, slippery  stretchable (spinnbarkheit)  ferning – on microscope assess cervical mucus daily avoid intercourse when cervical mucus is first noted to become more clear, stretchable and slippery and for about 4 days effectiveness the same as basal body temperature



Symptothermal Method o Ovulation o Menstrual calendar o Effectiveness: 98% (perfect use), 75% (typical use) 24

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Maternal and Child Nursing Mechanical Methods





Male condom Latex, plastic or natural membranes effectiveness: 97% (perfect use); 86% (typical use)



Female condom Thin polyurethane sheath with flexible rings at each end Cover the cervix, lines the vagina and partially shields the perineum May be inserted up to 8 hours before intercourse Effectiveness: 95% (perfect use); 79% (typical use)



Spermicides Kill spermatozoa before it reaches cervix Make vaginal pH strongly acidic Helps prevent STDs Active ingredient: nonoxynol Forms: a. contraceptive foam b. creams and jellies c. spermicidal vaginal tablet d. spermicidal condom e. film allergic reaction is possible must be applied with each act of intercourse onset of action varies Diaphragm Circular rubber disc fitted over cervix to prevent entrance of sperm cells into uterus Of different sizes Fitted by an obstetrician during: a. first time of use b. after every delivery/abortion c. weight loss of at least 10lbs largest size that fits is chosen inspect for tears and holes by holding against the light can be inserted 2 hours before intercourse but left for 6 hours after intercourse do not leave more than 24 hours complication: toxic shock syndrome a. elevation of temperature b. diarrhea and vomiting c. weakness and faintness d. muscle aches e. sore throat f. sunburn type rash effectiveness: 94% (perfect use), 80% (typical use)

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Maria Nazarethe A. Sulit| ©2009

Maternal and Child Nursing 

Cervical Cap Resembles a diaphragm but smaller with taller dome Insert at least 20 minutes but no longer than 4 hours prior to intercourse May be left in place for 48 hours

Hormonal Methods 

Contraceptive Pills Consist of estrogen and progesterone inhibit ovulation by suppressing FSH and LH cause thickening of cervical mucus alter motility of fallopian tubes 2 types of packets: a. 21 day pill – rest day of 7 days b. 28 day pill – last 7 pills either iron supplement or lactose Forms of OCP a. Combination Oral Contraceptives - contain both an estrogen and a progestin - formulations: 1. monophasic  contains fixed amount estrogen and progestin  e.g.: cyproterone/ethinylestradiol, Desogestrel/ethinylestradiol 2. biphasic  fixed or variable amount of estrogen  progestin increases in the 2nd half of the cycle  e.g.: desogestrel/Ethinyldestradiol  7 tabs 25 mcg progestin/40mcg estrogen  15 tabs 125mcg progestin/30mcg estrogen 3. Triphasic  amount of estrogen may be fixed or variable while amount of progestin increases in 3 equal phases  e.g., Levonorgestrel/Ethinyldestradiol  6 tabs 30 mcg progestin/50mcg estrogen  5 tabs 40 mcg progestin/75mcg estrogen  10 tabs 30mcg progestin/75mcg estrogen - effectiveness: 99.1% (perfect use), 95% (typical use) b. progestin-only pills (POPs) - “mini-pills” - contain low doses of progestins - considered in women seeking a highly effective, reversible and coitally independent method of contraception - action: a. prevents ovulation b. thickens cervical mucus and suppresses the endometrium - effectiveness with perfect use: 95.5% - with typical use: 95%

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Maternal and Child Nursing - warning signs and symptoms (ACHES) A – abdominal pain C – chest pain,cough H – headache, dizziness 

Norplant (Subdermal Implant) a. b.

six silastic capsules containing progestin implanted subdermally upper inner arm first 7 days of menstrual cycle action:

prevent ovulation stimulate production of thick cervical mucus



Long Acting Progestin Injections medroxyprogesterone acetate (Depo-Provera) 150mg IM every 3 months starting with 1st 5-7 days of the menstrual cycle blocks LH surge action: a. suppress ovulation b. thickens cervical mucus - effectiveness: 97.7%



Combination transdermal contraceptive patch Norelgestromin/ethinylestradiol 150mcg/20mcg per 24 hr patch apply 1 patch weekly x 3 weeks followed by 1 week patch free period. Women >90kg may find patch less effective Patch applied to clean, dry, hair-free skin on: buttock, abdomen, upper outer arm or upper torso Avoid irritated or broken skin, breasts or skin in contact with tight clothing/cosmetic



INTRAUTERINE DEVICE Contraception achieved by immobilizing sperm and impeding travel from cervix to fallopian tube Types: a. Progesterone T (progestasert)  for women allergic to copper b. Copper T380A (ParaGard)

c.

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 for women with at least 1 child  can be left in place x 10 years Levonorgestrel  Suited for women with heavy menstruation  Inserted in uterus during 1st 7 days of menstrual cycle  Effective x 5 years

Maria Nazarethe A. Sulit| ©2009

Maternal and Child Nursing

- warning signs & symptoms (PAINS) P – period late, abnormal spotting A – abdominal pain, pain with intercourse I – Infection exposure abnormal Discharges N – not feeling well, fever S – string missing Surgical Methods a. b.

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vasectomy tubal ligation

Maria Nazarethe A. Sulit| ©2009