Maternal And Child Health I
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- Words: 21,086
- Pages: 772
Lecturer: JHORAM F. NUFABLE, M.D.
A.
B.
Two hip bones (right and left innominate: Sacrum, coccyx). Innominate bones are consists of the: 1. Ilium 2. Ischium 3. Pubis
1. False pelvis – upper portion above pelvis brim, supportive structure for uterus during last half of pregnancy.
2.True pelvis – below brim; pelvic inlet, midplane, pelvic outlet. Fetus passes through during birth
PELVIS Four Types: 1.Gynecoid Pelvis 2. Android Pelvis 3. Anthropoid Pelvis 4. Platypelloid Pelvis
1.Gynecoid Pelvis Inlet is round Wide This is the typical FEMALE PELVIS Most favorable for normal spontaneous delivery
2. Android Pelvis Wide HEART-SHAPED This is the typical MALE PELVIS
3. Anthropoid
Pelvis Wide Narrow This is the typical APE PELVIS
4. Platypelloid Pelvis Opposite of Anthropoid Pelvis Wide Narrow
A.
Diagonal conjugate – 12.5 cm or greater is adequate size, evaluated by examiner
C.
Conjugate vera – 11 cm is adequate size; can be measured by x-ray (not commonly performed)
C. Obstetric conjugate – measured by x –ray (not commonly performed) D. Tuber-ischial diameter – 9 -11 cm indicates adequate size; evaluated examiner.
DIAMETERS OF THE PELVIS Sagittal section Obstetric Conjugate ◦ A conjugate that CANNOT BE MEASURED CLINICALLY ◦ Distance from posterior surface of symphysis pubis up to the most prominent portion of sacral promontory
Subtract 1.5 – 2.0 cm from diagonal conjugate Therefore, Obstetric Conjugate (OC) is equal to Diagonal Conjugate (DC) minus 1.5 to 2.0 centimeters. In equation form:
◦ OC = DC – 1.5 or 2.0 cm
Diagonal Conjugate Distance from posterior surface of symphysis pubis and the inferior margin of symphysis pubis up to the most prominent area of the sacrum Only conjugate that can be measured clinically Normal value is 11.5 cm to 12.5 cm.
A. B. C.
D. E.
F. G.
Mons veneris – protects symphysis Labia majora – covers, protects labia minora Labia minora – two located within labia majora Clitoris – small erectile tissue Hymen – thin membrane at opening of vagina Urinary meatus – opening of urethra Bartholins glands – producer of alkaline secretions that enhances sperm motility, viability.
Vagina – outlet for menstrual flow, depository of semen, lower birth canal
Cervix – cone-shaped neck of the uterus that protrudes into the vagina
OVARY Ovulation is the most important function of the ovary Production of the female hormone Situated retroperitoneally
Contained in the OVARIAN FOSSA In times of abdominal new growth in the ovary – these are always detected late due to anatomical location Example: ◦ Ovarian carcinoma ◦ Ovarian malignancy Not easily palpable
UTERUS Changes occurring during pregnancy Endometrium lining during pregnancy becomes deciduas (lining of the pregnant uterus) Endometrium is the lining of the NONPREGNANT UTERUS
2.
Decidua Basalis Decidua immediately beneath the implantation of the blastocyst
2. Decidua Capsularis Decidua covering the blastocyst
3. Decidua Vera This is the remaining portion of the decidua Decidua that is not Basalis nor Capsularis
Desidua Basalis
◦ Most important among the deciduas ◦ Limits invasion of CHORIONIC VILLI into the MYOMETRIUM ◦ Placenta will not be delivered spontaneously if basalis is NOT WELL DEVELOPED ◦ This will result into a condition known as PLACENTA ACCRETA
Placenta Accreta ◦ Presence of faulty attachment of the chorionic villi of the placenta into the myometrium ◦ The main problem in Placenta Accreta is HEMORRHAGE
◦ Therefore, the decidua basalis should be well developed
FALLOPIAN TUBE Site of fertilization More specifically, the AMPULLA of the Fallopian Tube is the site of fertilization Distal Third of the Fallopian Tube Composed of the ◦ Ampulla and Fimbriae
Ampulla ◦ Has the widest diameter among the segments of the fallopian tube
Middle Third of the Fallopian Tube ◦ Composed of the ISTHMUS
Proximal Third of the Fallopian Tube ◦ Composed of the INTERSTITIAL SEGMENT or the INSTERSTITIAL PART
a.
Health history 1. menarche; onset and duration 2. menstrual problems 3. contraceptive use 4.Pregnancy history fertility problems lifestyle
B. Physical examination 1. external, internal reproductive organs 2. breast examination 3. mammography – every 1-2 years for women beginning 40 annually beginning age 50 more frequently if have risk factors for breast cancer.
C. Pap smear – first Papaniculaou smear at age 18 or earlier if sexually active; then annually until 3 consecutive normal Pap smear. D. Test for sexually transmitted disease.
1.
Follicle stimulating hormone (FSH) – secreted during the first half of cycle; stimulates development of graafian follicle; secreted by anterior pituitary gland.
2. Interstitial cell- stimulating hormone, or leuteinizing hormone (ICSH, LH) - stimulates ovulation and development of corpus luteum; secreted by pituitary gland.
3. Estrogen – assists in ovarian follicle maturation; stimulates endometrial thickening; responsible for development of secondary sex characteristics; maintains endometrium during pregnancy. secreted by ovaries and adrenal cortex during cycle and by placenta during pregnancy.
4. Progesterone – aids in endometrial thickening; facilitates secretory changes; maintains uterine lining for implantation and early pregnancy; relaxes smooth muscle. Secreted by corpus luteum and placenta.
5. Prostaglandins – substances produced by various body organs that act hormonally on the endometrium to influence the onset and continuation of labor. Used to efface the cervix before induction of labor in term pregnancies.
Puberty ◦ ◦ ◦
Begins with the first menstrual bleeding (menarche) Begins when GnRH, FSH, LH, estrogen, and progesterone levels increase Increased estrogen and progesterone promote the development of the female primary and secondary sexual characteristics
Menstrual Cycle ◦ Consists of the periodic changes occurring in the ovaries and uterus of a sexually mature, nonpregnant female that result in The production of a secondary oocyte Preparation of the uterus for implantation
◦ Days 1-5: Menstrual phase: uterus sheds all but the deepest part of the endometrium ◦ Days 6-14: Proliferation phase: endometrium rebuilds itself ◦ Days 14-28: Secretory phase: endometrium prepares for implantation of the embryo
First half of the ovarian cycle Always variable in length Follicles of ovaries are growing Uterus lining (endometrium) is proliferating Elevated Hormones
Anterior Pituitary INCREASES SECRETION OF FOLLICLE STIMULATING HORMONE ◦ Therefore, the follicle in the ovary ENLARGES ◦ As it enlarges, it becomes more mature
GRAAFIAN FOLLICLE ◦ ◦ ◦ ◦ ◦
Most mature of all follicles With cavity With ovum ready to be extruded With clear fluid rich in ESTROGEN Only one (1) follicle matures per menstrual cycle
Approximate number of growing follicles: ◦ At twenty-eight (28) weeks Age of Gestation 6,000,000
◦ At Term 1,000,000
◦ At menarche 400,000
◦ At forty (40) years of age 8,000
Thickens the uterine lining Usually eight-fold of previous
◦ From one millimeter to eight millimeter
Peak of uterine lining coincides with ovulation Peaking of Estrogen will signal Leutinizing Hormone surge or increase in blood levels of Leutinizing Hormone
LH Surge Coincides with ovulation Extrusion of ovum from the Graafian Follicle Signal for Ovulation Ovum stays in the Fallopian tube for one (1) to three (3) days Peak is twenty-four hours
Second half of the ovarian cycle Constant part ◦ Always fourteen (14) days in length
Production of Corpus Luteum ◦ Uterus / uterine lining is secretory in nature
Because of the secretion of Leutinizing Hormone ◦ ◦ ◦ ◦
Leutinizing Hormone influences follicle Cavity is left inside the follicle Stimulates change in fluid in Graafian follicle Yellowish, milky white fluid high in PROGESTERONE
Progesterone Maintains uterine lining Organizes uterine lining ◦ If only estrogen is present, the uterine lining would continue to thicken and thicken and thicken
PRO-VERA ◦ Progesterone ◦ For dysfunctional uterine bleeding ◦ For organization of the uterus
Anticipates possible fertilization If there is pregnancy, to MAINTAIN PREGNANCY
If ovum degenerates, ◦ LH and Progesterone no longer needed ◦ Therefore, there is menstruation
If there is coitus and fertilization Corpus Luteum must persist up to twelve (12) weeks of gestation After twelve (12) weeks, it degenerates and the placenta produces hormones
Approximate menstrual cycle NORMAL is 28 days 28 + or – 7 days or 21 – 35 days is also NORMAL If the menstrual period is short (i.e. 21 days), a person can menstruate twice in a month – this is still NORMAL
If a person’s menstrual cycle is 28 days, 14 days for the proliferative or follicular phase and 14 days for the secretory or luteal phase, then OVULATION IS ON THE 14TH DAY If a person’s menstrual cycle is 35 days, the OVULATION IS ON THE 21ST DAY
Given the following: Last Menstrual Period (LMP) is January 1, 2005 Menstrual Cycle is 35 days
January 2005 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 February 2005 xx xx xx 01 02 03 04 05 06 07 08 09 10 11
The LAST MENSTRUAL PERIOD or LMP is the FIRST DAY OF THE PERIOD ◦ Therefore, counting of the MENSTRUAL CYCLE, starts from this same date ◦ Thus, February 4, 2005 Is the 35th day Is the expected start of the next cycle
Is the LMP of the next cycle
Thus, February 3, 2005
Is the 34th day Is the end of the cycle that started on January 1, 2005 This is WHERE YOU START COUNTING BACK FOURTEEN DAYS TO GET THE DAY OF OVULATION
Therefore, count fourteen (14) days, starting February 3 going backward
Thus, the expected OVULATION DAY is February 21, 2005
If the cycle is irregular, do not do this procedure If the Menstrual Cycle is not given, it is UNDERSTOOD THAT IT IS 28 DAYS
CONSTANT OF 11 AND 18 Another way of getting the ovulation period if the cycle is variable is by the use of the constant of 11 and 18
Example: ◦ Menstrual Cycle is 22 – 35 days ◦ Monitor the menstrual cycle in one year’s time ◦ Subtract higher number (18) from shortest cycle 22 – 18 = 4
◦ Subtract lower number (11) from the longest cycle ◦ 35 – 11 = 24
Therefore, from the 4th to the 24th day of the cycle, there is NO COITUS ◦ There is 80% failure in the rhythm method
If menstrual cycle is 28 – 35 days ◦ 28 – 18 = 10 ◦ 35 – 11 = 24
Therefore, from the 10th to the 24th day of the cycle, there is NO COITUS
Egg –approximately 24 hours after ovulation. Sperm – approximately 72 hours after ejaculation into female reproductive tract. Implantation (nidation) – occurs within 7 -9 days of conception, or about day 21 – 23 of a 28 day menstrual cycle.
Conception (fertilization) – usually occurs within 12 -24 hours after ovulation, within fallopian tube. Ovum – period of conception until primary villi have appeared; about 12 – 14 days
EMBRYO Product of Fertilization Approximately 3 cm; 54 – 56 days Pre-embryonic Period ◦ Zero (0) to two (2) to three (3) weeks
Embryonic Period ◦ Two (2) to three (3) weeks to eight (8) to ten (10) weeks
FETUS Period from end of embryo stage until birth. Eight (8) to ten (10) weeks up to time of delivery
VIABILITY A fetus can be delivered Capable of living outside utero Period of Viability is TWENTY (20) WEEKS AND ABOVE
GRAVIDA Number of pregnancies REGARDLESS OF THE OUTCOME PREGNANT WOMAN d. Nulligravida – never been pregnant e. Primigravida – first pregnancy f. Multigravida – a woman with a second or later pregnancy
PARITY Number of pregnancies THAT REACH THE AGE OF VIABILITY REGARDLESS OF THE OUTCOME OF PREGNANCY (should be delivered) Refers to the past pregnancies ( not number of babies) that reached viability (20-22 wk whether or not born alive)
NULLIPAROUS A woman who has not carried a pregnancy to viability (may have had one or more abortions) Pregnancy did not reach age of viability ◦Therefore, PRIMIGRAVID, NULLIPAROUS
Primipara – a woman who has carried one pregnancy to viability. Multipara – a woman who had two or more pregnancies that reached viability. Grandmultipara – woman who has had six or more viable pregnancies.
GTPAL G - describes number of gravida (pregnancy) T is for Term (37 weeks and above) P is for Pre-term (20 to 36 weeks) A is for Abortion (any terminated pregnancy less than 20 weeks; 19 wks and below) L is for Living children
Presumptive ◦ More of a symptom rather than a sign
Possible Positive
PRESUMPTIVE SYMPTOMS – subjective experiences 2. Amenorrhea more than 10 days past missed menstrual period. Breast tenderness, enlargement Nausea and vomiting Quickening (wk 16-18) Urinary frequency Fatigue Constipation (50% of women)
Presumptive signs Striae gravidarum linea negra, chloasma (after 6 week) Increased basal body temperature
Probable signs - examiner’s objective findings positive pregnancy test Enlargement of abdomen/uterus Reproductive organ changes (after six week)
3. Changes in Urination Urinary frequency ◦ Present in First and Third Trimester ◦ No Urgency
Second Trimester ◦ This disappears ◦ Uterus starting to enlarge in First Trimester ◦ Uterus becomes abdominal organ in the second trimester ◦ This releases pressure on the bladder
Third Trimester Uterus enlarges and presses again against the bladder in the Third Trimester
4. Nausea and Vomiting Human Chorionic Gonadotropin ◦ Primigravida Mostly manifests this
Peaks at FIRST TRIMESTER ◦ At two (2) to three (3) months of pregnancy ◦ At eight (8) to twelve (12) weeks of pregnancy
Provide: Dry unsalted crackers Ice chips Small, frequent feedings Six (6) times a day This is the best among all the options
Split food into two halves and give meals after every two (2) hours Less fatty foods in diet Do not lie supine after eating Encourage ambulation
Progesterone decreases gastric emptying! If nausea and vomiting is severe consider ◦ Hydration ◦ Vomiting ◦ Hypokalemia, presenting as generalized weakness ◦ Electrolyte Balance
Therefore, client needs to be admitted
5. Fatigue Diaphragm does not descend upon inspiration
6. Skin Changes Brought about by hormonal changes ESTROGEN ◦ Cloasma Mask of pregnancy Visible at the cheek
◦ Melasma Darkening of the neck
◦ Linea Negra From the symphysis pubis to the umbilicus
◦ Striae Gravidarum Silvery in color Due to distention of the collagen of the abdomen as the uterus enlarges
PROBABLE SIGNS More of the signs 1. Abdominal Enlargement Symmetrical and globular High risk Less than eighteen (18) weeks
See different Landmarks:If uterus is at the level of the symphysis pubis ◦ Age of Gestation = 12 weeks
If uterus is midway between umbilicus and symphysis pubis Age of Gestation = 16 weeks
If uterus is at the level of the umbilicus ◦ Age of Gestation = 20 weeks
Then, increase of one centimeter (1 cm) in FUNDIC HEIGHT = Additional Four (4) weeks in Age of Gestation ◦ ◦ ◦ ◦
1 2 3 4
cm cm cm cm
above above above above
the the the the
umbilicus umbilicus umbilicus umbilicus
= = = =
24 28 32 36
wks wks wks wks
At the LEVEL OF THE XIPHOID PROCESS, Age of Gestation is 36 weeks If one centimeter (1cm) below the xiphoid process, Age of Gestation is 40 weeks due to LIGHTENING (presenting part enters the true pelvis) or DESCENT
Lightening or Descent occurs ◦ In Primigravida Two weeks earlier
◦ In Multigravida Occurs during the time of labor
2. BALLOTTEMENT When you tap the uterus, there is a sensation that something is sinking and floating Sinking and floating of fetus in the uterus Appreciated at sixteen (16) to twentyfour (24) weeks only After twenty-four weeks (> 24 weeks), NO BALLOTEMENT OCCURS
This is because the size of the baby is greater in respect to the amniotic fluid
3. BRAXTON HICKS False labor Palpable uterine contraction Starts at approximately twenty-eight (28) weeks and above This is okay unless it does not give progressive cervical dilatation
4. CHADWICK’S SIGN Bluish-purple coloration of the vagina due to increase in vagina’s vascularity Vagina becomes swollen due to estrogen and progesterone purple hue in vulvar/ vaginal area.
Increase in acidity of vaginal pH due to lactobacillus acidophilus Lactobacillus acidophilus protects the vagina from ascending infection but favors increased growth of candidiasis Candidiasis
◦ This problem increases in pregnancy
5. GOODEL’S SIGN Softening of the cervix to ready cervix for dilatation and effacement Increased vascularity (red and bluish cervix) Hyperplasia and hypertrophy of cervical glands (uterus hypertrophy only) – cervical softening.
Increased cervical glands Increased cervical secretions Leukorrhea or white secretions Cervical secretions coagulation or clumping resulting into MUCOUS PLUG or OPERCULUM Operculum
◦ Protects the baby and the placenta from ascending infection
Hegar’s sign – softening of the lower uterine segment
POSITIVE PREGNANCY TEST HCG levels determine this Ten (10) days after missed period, this can be detected
Peak of level of HCG is ten (10) weeks Age of Gestation or 2½ months Then it goes down Therefore, yield of positivity of pregnancy tests to go down after ten (10) weeks
1. FETAL HEART TONE 1.1) Ultrasound ◦ Cardiac pulsation as early as six (6) to eight (8) weeks 1.2) Doppler Fetal heart tone at ten (10) to twelve (12) weeks
1.3) Fetoscope / Stethoscope Fetal heart tone at eighteen (18) to twenty (20) weeks
1.4) External Electronic Fetal Monitor Fetal heart tone at twenty-four (24) weeks Age of Gestation
2. QUICKENING Quickening felt by the examiner is a positive sign of pregnancy Quickening felt by the mother is a presumptive sign In Primigravida
◦ This occurs later than twenty (20) weeks
In Multigravida
◦ This occurs earlier than sixteen (16) weeks
3. X-RAY / FETAL SKELETON APPRECIATED X-ray on pregnant mother is okay as long as there is ABDOMINAL SHIELD This is done on the SECOND (2nd) or THIRD (3rd) TRIMESTER but NEVER DURING THE FIRST (1st) TRIMESTER
4. PULSATION OF HEART OF BABY THROUGH ULTRASOUND MATERNAL PHYSIOLOGY Pregnancy Duration ◦ 280 days
- 40 weeks - 10 lunar month s
1. WEIGHT GAIN Twenty-five (25) to thirty-five (35) pounds First Trimester ◦ Four pounds (4 lbs.) ◦ Only organogenesis occurs ◦ No muscle growth
Second Trimester ◦ Eleven pounds (11 lbs.)
Third Trimester ◦ Eleven pounds (11 lbs.)
One (1) to two (2) pounds per week is the allowable weight gain during the FIRST (1st) and SECOND (2nd) TRIMESTER
On the LATE THIRD TRIMESTER (36 weeks and above), allowable weight gain is one pound per week (1 lb. / week)
2. WATER METABOLISM Four (4) to six (6) liters of water are retained during pregnancy Thirty to fifty percent (30% to 50%) of this amount can enter into the circulation (approximately 2 – 3 liters) to intravascular space
This INCREASES the CARDIAC OUTPUT Therefore, pregnant people with HEART CONDITIONS are AT-RISK!!!
Increased Progesterone ◦ Relaxes smooth muscles ◦ Decreases peripheral resistance
Therefore, Blood Pressure should REMAIN THE SAME or should DECREASE DURING PREGNANCY
Sodium ◦ Dilutional Hyponatremia occurs in pregnancy due to increased water retention ◦ Therefore, DO NOT RESTRICT SALT INTAKE DURING PREGNANCY
Just maintain sodium intake of three (3) grams per day
3. PHYSIOLOGIC ANEMIA Due to increase in plasma value ◦ Dilutes circulating Red Blood Cells ◦ Therefore, take the Complete Blood Count in the initial assessment to get the blood picture of the client
Give iron supplementation ◦ Do this in the second trimester because this is the time when iron stores are depleted ◦ Best taken at night ◦ Metallic taste is ◦ Give with food
A gastric irritant ◦ ◦ ◦ ◦
Followed by orange juice Acidic environment provides greater absorption Advise that client will have black stool Client taking iron is constipated
Therefore, increase oral fluid intake and iron
4.CARBOHYDRATE METABOLISM Pancreas is enlarged ◦ Increased insulin secretion ◦ Pregnancy is a diabetogenic state ◦ A paradox!!!
If pre-pregnant mother is diabetic
◦ Two to three percent (2% to 3%) chance of having gestational diabetes ◦ Placenta COUNTERACTS INSULIN by INSULINASE ◦ Insulinase breaks insulin
Human Placental Lactogen
◦ Secreted only during pregnancy ◦ Promotes lipolysis
INSULINASE and HUMAN PLACENTAL LACTOGEN ◦ Increased sugars in blood prevents starvation of baby in case of maternal starvation
5. PROTEIN METABOLISM Increase in need of protein during pregnancy Additional ten grams (10 g) of protein per day to be added to non-pregnant diet
Placenta is made up of fatty acids FAT METABOLISM
◦ Add to diet ◦ A little increase in fat in the diet is necessary
Iron supplementation in pregnancy is DOUBLED In pre-pregnancy
◦ Fifteen grams per day (15 g / day)
In pregnancy Thirty grams per day (30 g / day)
1. HISTORY 2. PHYSICAL EXAMINATION 2.1) Take Blood Pressure Well rested mother for fifteen (15) minutes Blood Pressure Variations with Position
Sitting ◦ BP is slightly higher ◦ Highest reading of the three positions
Supine ◦ Intermediate reading
Left Lateral Lowest reading among the three positions
2.2) IPA In pregnant women, assessment would consist of: ◦ Inspection ◦ Palpation ◦ Auscultation
NO PERCUSSION
2.3) FOCUS ON ABDOMEN Inspection
◦ Look for striae ◦ Look for hernia of umbilicus
Palpate ◦ ◦ ◦ ◦
Take the fundic height Supine position with both legs flexed Use centimeter scale of tape measure Place at TIP OF SYMPHYSIS PUBIS up to the level of FUNDUS AND NOTE THE MEASUREMENT
2.4) PERFORM LEOPOLD’S MANEUVER Purpose of Leopold’s Maneuver
◦ To know where the fetal back is ◦ To get Fetal Heart Tone
Let patient void before performing Leopold’s Maneuver In the first three maneuvers, the nurse FACES THE HEAD PART OF THE MOTHER
2.4.1) LEOPOLD’S 1 Performed to know. . . What part of the baby occupies the fundus of the uterus?
FUNDAL GRIP How is Leopold’s 1 done? Use both hands Palpate the fundus of the uterus in a circular manner
Locate if the fundus has: ◦ HEAD
Round Hard Ballottable mass
◦ BREECH (buttocks) Soft Irregular With nodulations (coccyx, bilateral aspect of buttocks)
Question: What Leopold’s maneuver will you use to know the presentation of the fetus? Answer: Leopold’s 3
In Leopold’s 1, we know what is the LIE of the baby FETAL LIE
◦ Is the relationship of the long axis of the mother to the long axis of the baby
Types of Fetal Lie Transverse Lie
◦ Baby is perpendicular to the long axis of the mother ◦ HORIZONTAL ORIENTATION
Longitudinal Lie ◦ Baby is parallel to the long axis of the mother
VERTICAL ORIENTATION
If baby is in a TRANSVERSE LIE, LEOPOLD’S 1 is NEGATIVE
LEOPOLD’S 2 Performed to know. . . Where is the FETAL BACK? Where is the UMBILICAL GRIP?
How is Leopold’s 2 done? Use both hands Palpate the side of the mother
If at longitudinal lie ◦ Fetal Back Bony, convex mass represents the vertebral column
◦ Fetal Small Parts Small, irregular mass represents the knuckles and knees
If at transverse lie ◦ Head or Buttocks will be located
If you locate the back, place stethoscope at the back where FETAL HEART TONE is MOST AUDIBLE
LEOPOLD’S 3 Performed to know. . . What part of the baby lies just above the pelvic inlet PAWLIK’S GRIP
How is Leopold’s 3 done? Use dominant hand Grasp area just above the symphysis pubis If you grasp the head
◦ Round ◦ Hard ◦ Ballotable mass
If breech ◦ Soft ◦ Irregular ◦ With nodulations (coccyx, bilateral aspect of buttocks)
You will ALSO KNOW if PRESENTING PART IS ENGAGED or NOT ENGAGED
If head is engaged, ◦ If head is already descended, you will not feel the head ◦ If head has not descended fully to the pelvic inlet (partial descent), you can feel for the shoulders of the baby ◦ If head is unengaged, you can grasp head and you can move it sideways
FETAL PRESENTATION is best determined by LEOPOLD’S 3 because IT IS DIRECT. LEOPOLD’S 1 is INDIRECT
LEOPOLD’S 4 Performed to know. . . What is the ATTITUDE of the fetus? FETAL ATTITUDE
◦ This is the degree of flexion of the baby in utero
Types of Fetal Attitude Flexed Suboccipitobregmatic
diameter is presented Approximately nine centimeters (9cm) Note: Bregma is anterior
Extended It cannot pass through suboccipitomental diameter, which is greater than thirteen centimeters (>13 cm) Thus, there will be LONG LABOR Cervical Dilatation will not proceed Therefore, CAESARIAN SECTION is PERFORMED
You also note the DEGREE OF FLEXION or ATTITUDE of the fetus or PELVIC GRIP
How is Leopold’s 4 done? Face the foot part of the mother Use both hands Palpate the side of the mother going to the midline of the symphysis pubis
If in extension attitude ◦ There is RESISTANCE ◦ This occurs when you hit NAPE AREA
Note: Your hand will feel a depression and then will feel the ascending curve going towards the head
If in complete flexion ◦ Cephalic prominence is on the same side as fetal small parts (feet and knees)
If in complete extension ◦ Cephalic prominence is on same side of fetal back
Two (2) things to know from LEOPOLD’S 4 ◦ Fetal Attitude or the degree of flexion ◦ Cephalic Prominence
Prepare mother psychologically during prenatal check-up
FIRST TRIMESTER Mother should accept that she is pregnant (though ambivalence may be present) Concern of the mother towards herself is greater than her concern towards the baby
SECOND TRIMESTER Acceptance of baby is the main task Concern towards the self is EQUAL to concern for the baby
THIRD TRIMESTER Acceptance of parenthood Concern for the self is LESS than concern for the baby
a. b. c.
Once monthly – until week 28. Every 2 week – week 28 – 36 Weekly – week 36 until labor
THEORIES OF PARTURITION FETAL SIGNAL The baby feels that it is already capable of living outside utero
Example: ◦ Fetus with Normal Spontaneous Delivery go into Post Maturity, delivered 42 – 43 weeks ◦ This is because fetus feels something is still lacking in his or her body
OXYTOCIN THEORY OF PARTURITION Receptors for oxytocin in the uterus increases as term approaches
Level of progesterone assayed in pre-term and term pregnancy Pre-term
◦ Progesterone level is still high
Approaching Term ◦ Level of progesterone DECREASES causing CONTRACTION OF THE UTERUS
Premature ◦ Low levels of prostaglandin
Term / Post Term ◦ High levels of prostaglandin
Important Concepts! Prostaglandin causes uterine contraction
COITUS is CONTRAINDICATED if you have a history of PREMATURITY since SEMEN CONTAINS PROSTAGLANDIN
1. PELVIC DIMENSION 2. FETAL DIMENSION
A) Fetal Size Correlation of size of baby to pelvic size Cephalopelvic Disproportion (CPD) Head of baby is INCONGRUENT with the pelvis Head Size is greater than the Pelvis
B) Fetal Posture or Attitude If in complete extension, labor will not progress C) Fetal Lie If fetus is in TRANSVERSE LIE, DILATATION will NOT PROGRESS
D) Fetal Presentation If breech and PRIMIGRAVIDA NO NORMAL SPONTANEOUS DELIVERY If breech and MULTIGRAVIDA POSSIBLE NORMAL SPONTANEOUS DELIVERY
E) Fetal Position Relationship of the four (4) quadrants of the pelvis of the mother to the presenting part
F) Fetal Station Relationship of presenting part to ISCHIAL SPINES If head of baby descends in the pelvis, the head of the baby is AT THE LEVEL OF THE ISCHIAL SPINE
THEREFORE, STATION IS ZERO 1 cm above ischial spine = -1 2 cm above ischial spine = -2 3 cm above ischial spine = -3 4 cm above ischial spine = -4
At station of –4, head is still floating The presenting part is in the FALSE PELVIS The LINEA TERMINALIS is an imaginary dividing line that
divides the FALSE and TRUE PELVIS Above the linea terminalis is the FALSE PELVIS Below the linea terminalis is the TRUE PELVIS
If engaged, head is not necessarily at STATION ZERO From STATION –3, the head is ALREADY ENGAGED!!! Below the Ischial spine, the reckoning is POSITIVE
1 2 3 4
cm cm cm cm
below below below below
ischial ischial ischial ischial
spine spine spine spine
= = = =
+1 +2 +3 +4
At station +4, head is already CROWNING or SHOWING AT THE INTROITUS
3. FETAL HEAD Fontanelles ◦ Give rise to molding
Molding ◦ Overlapping of sutures to accommodate head through the pelvis
Anterior Fontanelle ◦ Diamond shaped ◦ Closes at nine (9) to eighteen (18) months
Posterior Fontanelle Triangular shaped Closes at two (2) to three (3) months
TRUE LABOR Starts at lumbar area or the back Regular interval Progressive cervical dilatation and effacement Intensity is increasing Ambulation intensifies uterine contraction in true labor Sedation has no effect
FALSE LABOR Confined to hypogastric area or lower abdomen Irregular interval No cervical dilatation and effacement No change or decreasing intensity Ambulation stops uterus contraction Sedation stops false labor
UTERINE CONTRACTION Timing is done by the nurse Use balls of the finger and palpate fundus of the uterus In the United States, the mother is hooked to an external monitor
Example: Contraction starts 7:00 AM Lasts 60 seconds 7:01 AM Second contraction 7:04 AM Duration is 60 secs 7:05 AM Third contraction 7:08 AM
Interval ◦ From end of first contraction to the beginning of the next contraction ◦ 7:01 AM to 7:04 AM ◦ Therefore, three (3) minutes
Frequency ◦ Beginning of one contraction to beginning of next contraction ◦ 7:00 AM to 7:04 ◦ Therefore, four (4) minutes
Duration ◦ From the beginning to end of one contraction ◦ 7:00 AM to 7:01 AM ◦ Therefore, one (1) minute
Intensity ◦ This is a subjective term ◦ May be classified as: Mild Contraction Examining finger can be indented but uterus is still contracting
Moderate Contraction Examining finger can be indented but uterine contraction is more than in mild
◦ Strong Contraction You cannot indent examining finger because the abdomen is board-like in consistency (hard)
1. LIGHTENING In Primigravida
◦ Two (2) weeks prior to labor
In Multigravida ◦ At time of labor
2. BRAXTON HICKS CONTRACTIONS Starting at twenty-eight (28) weeks Age of Gestation This is normal, provided there is NO CERVICAL DILATATION
3. INCREASE IN VAGINAL SECRETION An attempt to remove mucous plug
4. SOFTENING OF THE CERVIX HEGAR’S SIGN For effacement and dilatation
5. BLOODY SHOW Secondary to descent of presenting part Capillaries in the floor of pelvis are ruptured by presenting part or pressing on the pelvis
STAGE 1 TRUE UTERINE CONTRACTION TO FULL CERVICAL DILATATION (10 cm) For Primigravida (in normal circumstances) First Stage lasts for eight (8) to twelve (12) hours
For Multigravida (in normal circumstances) First Stage lasts for six (6) to eight (8) hours In Precipitate Labor Entire labor is through within three (3) hours
PHASE 1 LATENT PHASE OF FIRST STAGE OF LABOR Cervical Dilatation
◦ Zero centimeters (0 cm) to three (3 cm)
Uterine Contraction ◦ Duration Twenty (20) to Forty (40) seconds
◦ Interval Five (5) to ten (10) minutes
◦ Intensity Mild Intensity
PHASE 2 ACTIVE PHASE OF FIRST STAGE OF LABOR Cervical Dilatation
◦ Four centimeters (4 cm) to Seven (7 cm)
Uterine Contraction ◦ Duration Thirty (30) to Fifty (50) seconds
◦ Interval Two (2) to Five (5) minutes
◦ Intensity Moderate Intensity
PHASE 3 TRANSITIONAL PHASE OF FIRST STAGE OF LABOR Cervical Dilatation
◦ Eight centimeters (8 cm) to ten (10 cm)
Uterine Contraction ◦ Duration Up to sixty (60) seconds
◦ Interval Two (2) to three (3) minutes
◦ Intensity Strong Intensity
FROM FULL CERVICAL DILATATION UP TO DELIVERY OF THE FETUS In Primigravida
◦ One (1) to four (4) hours long
In Multigravida ◦ Twenty (20) to forty-five (45) minutes only
In a client in labor – A primigravida client, when will you transfer the client from the labor room to the delivery room? a.if cervix is fully dilated b.if in active labor c.if in transitional labor (8 – 10 cm) d. Anytime
Answer: ◦ Letter A
◦ If patient is Multigravida
Best time to transfer patient from the labor room to the delivery room is the TRANSITIONAL PHASE Transfer the client even while she is at eight centimeters (8 cm) dilatation
MECHANISMS OF LABOR IN VERTEX OR HEAD PRESENTATION
POSITION OF FETUS Relationship of the four (4) quadrants of mother to the presenting part Mother is facing you Symphysis pubis is ANTERIOR Vertebra of mother is POSTERIOR
Engagement Descent Flexion Internal Rotation Extension External Rotation Expulsion
Common Board Questions Give the correct sequence of the mechanisms of labor
DELIVERY OF BABY TO DELIVERY OF PLACENTA Lasts for five (5) to ten (10) minutes Maximum waiting time is thirty (30) minutes Beyond thirty (30) minutes is ALREADY ABNORMAL
1. Calkins’s Sign ◦ Uterus becomes firm and globular
2. Lengthening of the Cord
3. Sudden Gush of Blood 4. Rising of the Uterus into the Abdomen ◦ Up to the level of the umbilicus or one centimeter (1 cm) after umbilicus after the delivery of the placenta
Two (2) Types of Placental Expulsion Shultz Duncan
Shiny Cotyledon is not seen Total membrane covers this
Placental separation starts at fetal side of the placenta ◦ This is the membrane
Central separation is the start Less chances of bleeding
Nursing Responsibility for the Assessment of the Placenta ◦ Expose all cotyledons If one is missing, IT REMAINS INSIDE Look for the PUNCHED-OUT AREA
◦ Measure the placental diameter ◦ Weigh the placenta Remove the clamp Normal placental weight Less than 500 grams If greater than 500 grams, there is PLACENTO-MEGALY related to congenital anomaly
◦ Measure umbilical cord Measure portion of the cord remaining with the placenta Measure portion of the cord remaining with the baby
If this is less than fifty centimeters (<50 cm), there may be SHORT CORD SYNDROME related to ABRUPTIO PLACENTA
◦ Expect Blood Vessels
Artery Small round lumen Vein Bigger lumen More collapsed
◦ Two (2) arteries and one (1) vein ◦ Mnemonic is AVA ◦ If there is only one (1) artery and one (1) vein, there is a congenital problem – A GUT PROBLEM – Genitourinary Tract Anomalies
Placental separation starts at SIDE / PERIPHERY – on the lower end of the placenta Placenta slides down to the introitus Maternal side presents (attached to myometrium) Cotyledons are easily visible Associated with more bleeding and hemorrhage
Normal Range of Number of Cotyledons ◦ Sixteen to twenty (16 – 20)
When is the best time to clamp the cord? Best time to clamp the cord is when THE CORD STOPS PULSATING
When is the best time to cut the cord? ◦ Best time to cut the cord is when THE CORD STOPS PULSATING Pulsation means blood still flows
These drugs cause contraction of the uterus 1. ERGOTRATES Includes METHERGINE I.V. or I.M. Best given immediately after delivery of placenta Massive contraction of the uterus traps placenta inside
Therefore, do not give before placental expulsion
2. OXYTOCIN Given prior to expulsion of placenta to add to contraction Given at minimal amounts Normally at a rate of eleven to twelve drops per minute (11-12 gtts / min)
After delivery of placenta, give oxytocin at GREATER AMOUNTS
Important Nursing Considerations! Methergine ◦ Prior to administration, check blood pressure ◦ If BP is greater than 140/90, WITHHOLD METHERGINE
Oxytocin ◦ Never given in direct bolus ◦ Never push
◦ Causes UTERINE HYPERTONUS Tetanic contractions of the uterus or UTERINE ATONY
◦ Always dripped Ten (10) units with one (1) liter
Duration and Interval of Contraction in Uterine Atony / Hypertonus
◦ Duration of Contraction Greater than seventy seconds (>70 secs) In Transitional Phase of First Stage of Labor, duration of contraction is about sixty (60) seconds
◦ Interval Less than two (2) minutes This means that rest period is decreased
Maximum interval must be maintained at two (2) to three (3) minutes
Therefore, STOP INFUSION OF OXYTOCIN AS SOON AS POSSIBLE
DO PROCEDURES IN LATE DECELERATION
Oxytocin ◦ A potent vasoconstrictor ◦ Side effect Initially is HYPERTENSION
◦ If given in bolus Hypertension will be REVERSED TO HYPOTENSION
Therefore, DO NOT GIVE OXYTOCIN IN BOLUS
Also causes WATER INTOXICATION
◦ Therefore, assess lungs of client ◦ Crackles will be present due to pulmonary edema due to water retention by oxytocin
Bleeding or Hemorrhage Uterus must be at level of umbilicus or about one centimeter (1 cm) above
If it is three centimeters (3 cm) above the umbilicus, UTERUS IS NOT CONTRACTED ◦ There would be BLEEDING
First thing to do: ◦ Massage the uterus to attempt contraction ◦ Increase the rate of oxytocin drip Nurse does this
Rate is increased from ten drops per minute (10 gtt/min) to twelve to fifteen drops per minute (12 – 15 gtt/min) ◦ Place icepack over the abdomen Remove compress every ten minutes and replace This prevents necrosis and blackening of the tissues
Inspect Perineum ◦ How to measure amount of bleeding? ◦ Utilize the PADS Count and Weigh Guide: One gram is equivalent to one milliliter (1 g = 1 ml)
◦ Qualitative Approach Mild Bleeding One (1) pad saturated in one (1) hour
Moderate Bleeding One (1) pad saturated in thirty (30) minutes
Heavy Bleeding One (1) pad saturated in fifteen (15) minutes Heavy Bleeding Perineal pads saturated at one (1) hour and if blood clots are present
◦ Palpate Abdomen Uterus contracted Perineum has bleeding
Bleeding from episiotomy (done if there is crowning or +4 station) Laceration not appraised Bleeding from cervical laceration Most common cause of bleeding Vaginal wall bleeding
DO NOT ENCOURAGE PUSHING IF CERVIX IS NOT FULLY DILATED
Question When is the best time to ask client to push? Answer
◦ Second Stage of Labor
◦ Main purpose of pushing To shorten the Second Stage of Labor Ask client to PANT-BREATHE if there is an urge to push This prevents VALSALVA MANEUVER
Remember, FIRST STAGE PUSHING IS NOT ADVISABLE
In the Third Stage of Labor, the NURSING RESPONSIBILITY is to PROVIDE MEASURES TO PREVENT HEMORRHAGE
Other Causes of Bleeding Bladder Distention
◦ Therefore, MOTHER MUST VOID AFTER GIVING BIRTH ◦ Offer bedpan every hour or accompany the mother to the bathroom (patient has HYPOTENSION)
First twelve (12) hours post partum It is NORMAL for mother to go into DIURESIS Absorbed water must be eliminated
◦ After twelve (12) hours, there is difficulty in voiding due to FATIGUE BLADDER because of CONSTANT PRESSURE EXERTED BY CONTRACTING UTERUS This results to a DISTENDED BLADDER Therefore, UTERUS CANNOT CONTRACT EFFECTIVELY
This causes UTERINE ATONY (Uterus is deflected either to the LEFT or to the RIGHT) Therefore, assure voiding so uterus stays at center
Place warm water in container ◦ Do not place warm water in abdomen or at the hypogastric area ◦ This will cause bleeding
Nursing Responsibility ◦ Do alternate pouring of warm and cold water over the perineum to promote uterine contraction
FIRST ONE (1) TO TWO (2) HOURS AFTER DELIVERY OF THE PLACENTA Crucial Problem or Main Problem at this stage ◦ BLEEDING
All the retained water retained previously will be reabsorbed into the circulation ◦ Increase in Cardiac Output ◦ Increase in Oxygen Consumption
Therefore, it is the most detrimental or difficult stage of labor in GRAVIDOCARDIAC PATIENTS!!!
ABORTION Two (2) types of Abortion Spontaneous Abortion Induced Abortion
SPONTANEOUS ABORTION Spontaneous miscarriage oocurs in 15 to 30% of all pregnancies. Early miscarriage occurs before 16 weeks; late if it occurs 16 to 24 weeks Most common cause of spontaneous abortion is teratogenic factor and Chromosomal in nature Embryo is defective Immunologic, Implantation, Progesterone is too low, Infection, Ingestion of drugs.
Assessment: Vaginal spotting. Woman’s action is important. Therapeutic management: TYPES OF SPONTANEOUS ABORTION Threatened Abortion Incomplete Abortion Inevitable / Imminent Abortion Complete Abortion Missed Abortion
Threatened – mild bleeding, spotting, cramping; cervix closed. Inevitable – moderate bleeding, painful cramping cervix dilated Imminent – profuse bleeding, severe cramping , urge to bear down Incomplete – fetal parts or fetus expelled; placenta and membranes retained.
Complete – all products of conception expelled; minimal vaginal bleeding Habitual/recurrent – history of spontaneous loss of three or more successive pregnancies. Missed – fetal death with no spontaneous expulsion within 4 weeks. Elective abortion – (intentionally introduced loss of pregnancy
Threatened abortion: Blood is drawn to monitor human chorionic gonadotropin hormone Sonogram is done to assessed viability of fetus. Avoiding strenuous activity for 24 to 48 hours is the key intervention. Imminent(Inevitable abortion). For dilation and evacuation
Complete Abortion entire product of conception are expelled spontaneously without any assistance. Incomplete Abortion Danger of maternal hemorrhage. Dilation and curettage should be done. Missed Abortion Early pregnancy failure Died 4 to 6 weeks before the onset of miscarriage symptoms Over 14 weeks may perform induced labor Disseminated intravascular coagulation.
Recurrent Abortion Occurs in 1% of pregnant women. Possible causes: 4. Defective spermatozoa or ova 5. Endocrine factors 6. Deviations of uterus. 7. Infection 8. Autoimmune disorder
6. 7. 8. 9.
Danger in MISSED ABORTION is SEPSIS Particularly if products of conception stay for more than two (2) weeks, there is INFECTION and DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC) DIC may also occur from induced abortion (abortion with catheterization) Offending organism is gram negative anaerobe Other complications: Hemorrhage Septic abortion Isoimmunization Anxiety
◦ Gram negative organism secretes ENDOTOXINS Causes destruction of capillaries Results in turbulence in blood flow Blood will seep out through the capillaries Platelets will go to site of destruction Platelets consumed
Therefore, also called CONSUMPTIVE COAGULOPATHY
Disseminated Intravascular Coagulopathy patients: ◦ Die of continuous bleeding ◦ Have patches of hematoma ◦ Have hypotension leading to SEPTIC SHOCK due to dilatation caused by ENDOTOXIN ◦ Fibrinogen level are too low. ◦ Associated with premure separation of placenta, pregnancy induced hypertension, placental retention, septic abortion, retention of dead fetus.
In septic shock, the extremities are warm ◦ All other forms of shock have COLD EXTREMITIES
ECTOPIC PREGNANCY Implantation outside the uterus Mostly tubal in nature (95%): 80% Ampulla, 12% isthmus, 8% fimbria. 2nd most common cause of bleeding in early pregnancy Can be abdominal pregnancy Can be ovarian pregnancy Abdominal and ovarian pregnancy account for five percent (5%)
Most common predisposing factor ◦ PELVIC INFLAMMATORY DISEASE or PID ◦ Others chronic salpingitis, congenital malformation, scars, uterine tumor.
Other factors: ◦ Previous Surgery May lead to adhesion Peritoneum may adhere to fallopian tube
◦ Presence of Intrauterine Device ◦ History of previous ectopic pregnancy (on opposite side)
TRIAD OF MANIFESTATIONS Amenorrhea Vaginal bleeding or SPOTTING UNILATERAL ABDOMINAL PAIN or TENDERNESS
◦ Usually lower abdomen
CLINICAL MANIFESTATIONS OF ECTOPIC PREGNANCY Severe, sharp knife-like abdominal pain
◦ Unilateral pain
Abdominal rigidity ◦ Bleeding inside ◦ Hemoperitoneum ◦ Peritonitis
Positive (+) for Cullen’s Sign ◦ Ecchymosis around the umbilicus due to hemoperitoneum ◦ Sign of peritoneal irritation
Decreased Blood Pressure ◦ About 80 / 50
Excruciating Pain when the cervix is moved
In ectopic pregnancy, blood goes to the peritoneum ◦ Blood ruptures and pools at CUL DE SAC or the POUCH OF DOUGLAS or URETERORECTAL POUCH
When internal examination is done and cul de sac is palpated, WRIGGLING SENSATION arises
DIAGNOSIS FOR ECTOPIC PREGNANCY CULDOCENTESIS You get something from the cul de sac
How is Culdocentesis done? Consent Lithotomy position Prepare Perineum Speculum introduced
◦ Held in place
To visualize the cervix
◦ No anesthetic is given
Spinal needle directed towards posterior portion of the cervix Aspirate
If blood is present in the cul de sac, it is a RUPTURED ECTOPIC PREGNANCY If there is blood. . .
◦ It is tested to make sure it comes from ectopic pregnancy and NOT MATERNAL BLOOD ◦ Blood is placed in a test tube / disk and observed for clotting
If NON-CLOTTING OR LAKED BLOOD ◦ It comes from ectopic pregnancy
If BLOOD CLOTS It is maternal blood
MANAGEMENT FOR ECTOPIC PREGNANCY MEDICAL MANAGEMENT METHOTREXATE A sclerosing agent
◦ To shrink and absorb products of conception and eventual absorption to the circulation
If ectopic pregnancy is less than three centimeters (3 cm) ◦ Given I.M. to the mother
SURGICAL MANAGEMENT Salphingostomy Limited to UNRUPTURED (less than three centimeter (3 cm)) “binubutas, tinatanggal” Left to heal
Salphingotomy Limited to UNRUPTURED “binubutas, tinatanggal” Sutured Salphingectomy For a ruptured ectopic pregnancy
Conditions Associated with secondTrimester bleeding Hydatidiform mole (H-MOLE) Predisposing Factors: ◦ Low socio-economic status ◦ Low protein intake ◦ Age Less than eighteen (<18) Greater than thirty-five (>35)
PROBLEM IN H-MOLE There is an abnormal degeneration of the chorionic villi Vesicle-like structure is formed instead of placenta May be antecedent to choriocarcinoma
Genetic base of complete mole (sperm enters empty egg and its chromosomes replicates; 23 pairs of chromosomes are all paternal). More common in women over 45 years of age and women who are Asian.
A.
B.
C.
uterus – rapid enlargement; fundal height inconsistent with gestational estimate. Brownish discharge – beginning about wk 12; may contain vesicles. Signs and symptoms of preeclampsia/eclampsia (before third trimester), increased incidence of hyperemesis gravidarum.
1.
2.
sonography, x-ray, amniography – no fetal parts present; “snowstrom” Laboratory test – for elevated human chorionic gonadotropin (HCG) levels.
NURSING RESPONSIBILITIES IN H-MOLE SUCTION CURETTAGE “Sinisipsip” “Ayaw kayudin ang uterine lining”
Purpose of Suction Curettage ◦ To prevent cancer of CHORIONIC CARCINOMA ◦ To prevent bleeding ◦ Sinuses Open Early dissemination of tissues or METASTASIS to the lungs, brain
Lungs are the MOST common site of METASTASIS IN H-MOLE
Inability of cervix to support growing weight of pregnancy; associated with repeated spontaneous second trimester abortion.
Etiology Unknown Congenital defect in cervical musculature Cervical trauma during previous birth, abortion; aggressive, deep or repeated dilation and curettage
INCOMPETENT CERVIX / CERVICAL OS Most common cause of Habitual Abortion Habitual Abortion ◦ Three (3) consecutive abortions
PREDISPOSING FACTORS IN INCOMPETENT CERVIX Developmental Factors
◦ Defective collagen formation in the cervix
Repeated Trauma to the Cervix ◦ Repeated Dilatation and Curettage
MANIFESTATIONS OF INCOMPETENT CERVIX Minimal uterine contraction Vaginal Spotting Progressive dilatation of the cervix Already evident in the FIRST TRIMESTER
MANAGEMENT OF INCOMPETENT CERVIX McDonald’s Procedure Shirodkar / Barter Procedure
MC DONALD’S PROCEDURE Purse string suture applied to cervical opening ◦ Purpose is to make the cervix tense
Done if products of conception IS LESS THAN TWELVE (12) WEEKS OLD Mother is allowed to deliver by NORMAL SPONTANEOUS DELIVERY if pregnancy persists
SHIRODKAR / BARTER PROCEDURE Cervix is closed But menstrual blood is allowed to come out Delivery is via CAESARIAN SECTION
NURSING RESPONSIBILITIES IN INCOMPETENT CERVIX Bed Rest Position of choice ◦ Modified Trendelenberg ◦ Lumbar area is elevated and feet are lowered
Coitus is temporarily restricted
Tocolytic therapy is employed if there is contraction ◦ RITODRIN, TERBUTALLINE is administered to STOP CONTRACTION
Conditions Associated with ThirdTrimester bleeding PLACENTA PREVIA Important Concept! All previa types are CAESARIAN DELIVERIES !!!
FOUR (4) TYPES OF PLACENTA PREVIA 1. Low Lying Placenta Previa; Example: Gravida 7 Predisposing Factors Multiparity, Advanced maternal age, past cesarean, uterine curettage, multiple gestation, male fetus.
◦ Tumor or mass in the uterus ◦ Previous Caesarian Section Scar is avoided by the placenta
◦ Developmental Anomaly in the Uterus Bicornuate uterus
2. Marginal Placenta Previa Lower end of Placenta is TOUCHING THE INTERNAL OS 3. Partial Placenta Previa Part of placenta is OBSCURING THE INTERNAL OS
4. Total Placenta Previa Also called Placenta Previa Totalis Placenta TOTALLY COVERS THE INTERNAL OS
◦ Definitely a Caesarian Section!
Localization of Placenta ◦ Done on the second / third trimester
PLACENTAL MIGRATION Placenta moves and may move up Can occur up to thirty-two (32) weeks
Establish that the placenta is NOT PREVIA in ALL INSTANCES OF SECOND OR THIRD TRIMESTER BLEEDING ◦ Wait for the ULTRASOUND result
DO NOT DO INTERNAL EXAMINATION!!!
DOUBLE SET-UP Client with placenta previa
◦ If Internal Examination is done ◦ A stand-by team for operation is set up Due to the advent of the Ultrasound, a Double Set-up is NO LONGER DONE!!!
ABRUPTIO PLACENTA Normal Placement EARLY SEPARATION OF THE PLACENTA PRIOR TO DELIVERY OF THE FETUS Remember that separation of placenta normally occurs on the THIRD STAGE OF LABOR Frequent cause of perinatal death
In abruptio placenta, the abnormal separation OCCURS ON THE SECOND STAGE OF LABOR
If baby has SHORT CORD SYNDROME or TRAUMA, consider ABRUPTIO PLACENTA Pregnancy Induced Hypertension
◦ A common cause of Abruptio Placenta ◦ Advanced maternal age ◦ Vasoconstriction from cocaine or cigarette use
PERIPHERAL SEPARATION Better Safer Blood goes out of introitus Tachycardia Hypotensive Increases degree of separation Increases degree of fluctuation of vital signs
CENTRAL SEPARATION More dangerous Blood does not seep off through the introitus but enters MYOMETRIUM Results to difficulty in contraction of the Myometrium Uterus remains soft and boggy ◦ Uterine Atony
Therefore, HYSTERECTOMY IS DONE Called COUVELAIRE Uterus is COPPER-COLORED or BLUISH in color due to BLOOD THAT SEEPED INTO THE MYOMETRIUM
Degree of separation: Grade 0: no symptoms of separation were apparent from the maternal or fetal signs, the diagnosis that a slight separation did occur is made after birth. Grade 1: Minimal separation, but enough to cause vaginal bleeding and changes in maternal vital sigs. No fetal distress Grade 2: Moderate separation, there is evidence of fetal distress. Grade 3: Extreme separation, without intervention maternal shock and fetal death will result.
Preterm Labor Occurs before the end of week 37 of gestation. Responsible for almost two thirds of all infant deaths in the neonatal period. Associated with dehydration, urinary tract infection, chorioamnionitis, inadequate pre-natal care. Symptoms: 6. Dull, low back pain 7. Vaginal spotting 8. Feeling of pelvic pressure 9. Menstrual like cramping 10.Increased vaginal discharge
PREMATURE RUPTURE OF MEMBRANES Membranes rupture PRIOR TO ONSET OF LABOR No contractions yet
PROBLEMS IN PREMATURE RUPTURE OF MEMBRANES 1. INFECTION Gold Standard is twenty-four (24) hours If more than twenty-four hours, there will be SEPSIS
2. CORD PROLAPSE Umbilical cord goes out Position the client to TRENDELENBERG POSITION
◦ Lower the head part ◦ NICHE’S POSITION
Do not reinsert!!! Moisten OS with NSS and cover
Push the PRESENTING PART BACK and NOT THE CORD Transport client to the OPERATING ROOM Provide oxygenation Get Fetal Heart Tone Then Caesarian Section is started Never Normal Spontaneous Delivery
MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES Pregnancy can still be prolonged if PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM)
◦ Pre-term Premature Rupture of Membranes (i.e. 35 weeks)
Problems are: ◦ Infection ◦ Cord Prolapse ◦ Prematurity
Provided ◦ There is no maternal infection ◦ There is no fetal distress ◦ Mother is not in labor
Termination of Pregnancy ◦ Caesarian Section ◦ Normal Spontaneous Delivery
PREMATURE LABOR Most common cause of neonatal morbidity and mortality
◦ Eighty five percent (85%)
Preventable ◦ How?
Modify lifestyle of the mother Resolve on-going infection Ascending infection affects fetus, uterus (goes into contraction)
Management is similar to Placenta Previa Except coitus restriction throughout
POST TERM LABOR Pregnancy extends beyond forty-two (42) weeks 1. Cephalopelvic Disproportion (CPD) This leads to babies with
◦ Long nails ◦ Wrinkled Skin
2. Oligohydramnios Amniotic fluid is less than 1,000 ml Polyhydramnios is amniotic fluid level greater than 2,000 ml Related to congenital anomaly This gives rise to babies with BANDS OR CONSTRICTIONS ON BODY
3. Inadequate blood supply to the baby due to calcification of the placenta Placenta tends to harden There are whitish specks instead of black specks
4. Meconium Staining Due to distress Meconium Aspiration Syndrome
PRECIPITATE LABOR Course of labor is ABRUPT Labor lasts for LESS THAN THREE (3) HOURS
DANGERS OF PRECIPITATE LABOR Non-institutionalized Delivery
◦ Exposes baby to sepsis
Expose mother to laceration ◦ Head of baby bumps to pelvis This results to hemorrhage
Intracerebral hemorrhage of the head of baby ◦ Baby bumps to bony pelvis
BREECH DELIVERY 1. COMPLETE BREECH Baby assumes a position similar to sitting Thighs flexed to abdomen Legs flexed to thigh 2. FRANK Thighs are flexed to abdomen Legs are extended
3. INCOMPLETE BREECH Thighs are flexed to abdomen Either leg is extended outside
◦ Single Footling
Double Footling
MAIN PROBLEM Cord Prolapse
◦ Space in cervical opening ◦ Therefore, cord goes with presenting part
Head Entrapment Shoulder Dystocia
◦ Difficulty in bringing out shoulder
Normal to see Meconium Staining ◦ Buttocks get stuck Less blood supply to the gut Stress present Therefore, there is meconium
MULTIPLE PREGNANCY Two (2) types of Multiple Pregnancy Monozygotic Dizygotic
MONOZYGOTIC One (1) ovum and one (1) sperm Fertilized by single sperm Problem in cell division
Two (2) individuals Most of the time, of the same sex One (1) placenta Two (2) umbilical cords One (1) chorion (vascular outer covering)
◦ In contact with maternal side
Two (2) amnions (avascular inner covering) ◦ In contact with the fetus
DIZYGOTIC Two (2) ova and two (2) sperms fertilizing them Identical or twin of opposite sex Two (2) placenta Two (2) umbilical cord Two (2) amnions Two (2) chorions
MONOZYGOTIC TYPE OF MULTIPLE PREGNANCY ◦ More common
Increased chance of twin to twin transfusion
◦ Donor twin and recipient twin Blood of donor twin goes to recipient twin Because they share one vascular channel
◦ Donor Twin Survives Usually thin Would normalize and be okay after blood transfusion
◦ Recipient Twin Dies Develops Congestive Heart Failure Usually stout
Dystocia – difficult labor - Due to effects of factors that affect the FETUS. (3 P’s) a. Power: forces of labor (uterine contractions, use of abdominal muscles0. 1 premature analgesia/anesthesia 2. uterine overdistension (multifetal pregnancy, fetal macrosomia). 3. uterine myomas 4. grandmultiparity
b. PASSAGEWAY: resistance of cervix, pelvic structure. 1. rigid pelvis 2. distended bladder 3. dimensions of the bony pelvis: pelvic contractures
c. PASSANGER: accommodation of the presenting part to pelvic diameters. 1. fetal malposition/malpresentation a. transverse lie b. face, brow presentation c. breech presentation d. persistent occiput posterior position e. CPD 2. fetal anomalies a. hydrocephalus b. conjoined (“Siamese”) twins. c. meningomyelocele
Maternal: 2. fatigue, exhaustion, dehydration – due to prolonged labor 3. Lowered pain threshold, loss of control- due to prolonged labor, continued uterine contractions, anxiety, fatigue, lack of sleep. 4. Intrauterine infection- due to prolonged rupture of membranes and frequent vaginal examination 5. Uterine rupture – due to obstructed labor, hyperstimulation of uterus 6. Cervical, vaginal, perineal lacerations – due to obstetric interventions
Fetal: 2. hypoxia, anoxia, demise – due to decreased oxygen concentration in cord blood. 3. Intracranial hemorrhage – due to changing intracranial pressure.
Hypertonic dysfunction Increased resting tone of uterine myometrium; diminsihed refractory period; prolonged phase; Unknown etiology Theory- ectopic initiation of incoordinate uterine contractions. a. nullipara – more than 20 hours b. multipara – more than 14 hours
Assessment: 1.Onset – early labor (latent phase) 2.Contractions: a. continuous fundal tension, incomplete relaxation b. painful c. ineffectual – no effacement or dilation Signs of fetal distress a. meconium stained b. FHR irregularies 3. Maternal vital signs 4. Emotional status
Medical management: 2. Shorting acting barbiturates – to encourage rest, relaxation. 3. Intravenous fluids – to restore/maintain hydration and fluid-electrolyte balance. 4. If CPD, cesarean birth.
Nursing management: 2. Emotional support – assist coping with fear, pain, discouragement a. encourage verbalization of anxiety, fear concern. b. explain all procedure c. reassure, keep couple informed of progress.
2. Comfort measure a. position: sidelying – to promote relaxation and placental perfusion. b. bath, back rub, linen change, clean environment c. environment: quiet, darkened room – to minimize stimuli and encourage relaxation and warmth. d. encourage voiding – to relieve bladder distension; to test urine for ketones.
Hypotonic dysfunction during labor After normal labor at onset, contractions diminish in frequency, duration and strength; lowered uterine resting tone; cervical effacement and dilation slow/cease.
Etiology Premature or excessive analgesia (epidural block/spinal block) CPD Overdistention (polyhydramnios, fetal macrosomia, multifetal pregnancy). Fetal malposition/alpresentation Maternal fear/anxiety.
Assessment: 2. Onset – may occur in latent phase, most common during active phase 3. Contractions: normal previously, demonstrate: Decreased frequency Shorter duration Diminished intensity (mild to moderate) Less uncomfortable
3. Cervical changes – slow/ cease. 4. Signs of fetal distress
Uterine rupture Stress on uterine muscle exceeds its ability to stretch. Etiology Overdistention – due to large baby, multifetal gestation Old scars – due to previous cesarean births or uterine surgery Contractions against CPD, fetal malpresentation, pathological Tetanic contraction – due to hypersensitivity to oxytocin( or overdose) during induction/augmentation of labor. Injudicious obstetrics-malaaplication of forceps (application without full effacement/dilation.
Assessment: 2. Identify predisposing factors early. 3. Complete rupture: a. pain: sudden, sharp, abdominal; followed by cessation of contractions; tender abdomen. b. signs of shock; vaginal bleeding c. fetal heart tones – absent d. presenting part – not palpable on vaginal examination.
2. Incomplete rupture a. contractions: continue, accompanied by abdominal pain and failure to dilate; may become dystonic b. signs of shock c. may demonstrate vaginal bleeding d. fetal heart tone absent/bradycardia
Amniotic Fluid Embolus Acute or cor pulmonale – due to embolus blocking vessels in pulmonary circulation; massive hemorrhage due to DIC resulting from entrance of thromboplastin-like material into bloodstream.
Etiology: Amniotic fluid (with any meconium, lanugo, or vernix) enters maternal circulation through open venous sinuses at palcental site; travels to pulmonary arterioles. Triggers cardiogenic shock and anaphylactoid reaction.
Prognosis: Poor; often fatal to the mother
Assessment: 2. May occur during labor, at time of rupture of membranes, or immediately postpartum 3. Sudden dyspnea and cyanosis 4. Chest pain 5. Hypotension, tachycardia 6. Frothy sputum 7. Signs of DIC a. purpura – local hemorrhage b. increased vaginal bleeding – massive c. rapid onset of shock
Medical management: 2. IV heparin, whole blood 3. Birth, immediately, by forceps, if possible; or cesarean birth
Fetus in Jeopardy Maternal hypoxemia, anemia, ketoacidosis, Rh isoimmunization,or decrease uteroplacental perfusion
Etiology Maternal: 1. preeclampsia/eclampsia, PIH 2. heart disease 3. diabetes 4. Rh or ABO incompatibility 5. insuffient uteroplacental/cord circulation due to: a. maternal hypotension/hypertension. b. cord compression 1. prolapsed 2. knotted c. hemorrhage; anemia
Placental Problem; 1. malformation of the placenta/cord 2. premature “ aging” of placenta 3. Placental infarcts 4. abruptio placentae 5. placenta previa
Prolapsed umbilical cord Cord descent in advance of presenting part; compression interrupts blood flow, exchange of fetal/maternal gases leads to hypoxia, anoxia, death (if unrelieved)
Etiology: b. Spontaneous or artificial rupture of membranes before presenting part is engaged. c. Excessive force of escaping fluid, as in polyhydramnios. d. Malposition – breech, compound presentation transverse lie. e. Preterm or fetus who is SGA
PREGNANCY INDUCED HYPERTENSION (P.I.H.) Unknown cause Vasospasm
SCREENING PROCEDURE FOR PREGNANCY INDUCED HYPERTENSION 1. ROLL-OVER TEST Done when mother is ◦ Twenty-eight (28) to thirty-two (32) weeks Age of Gestation
With increased cardiac output ◦ Mother is rested for fifteen (15) minutes ◦ Take the blood pressure in sitting position (assuming BP is 100/60)
◦ Rest mother for fifteen (15) minutes ◦ Get blood pressure at left lateral position (assuming BP is 90/60) ◦ Place mother in supine position ◦ Take the BP in supine position (assuming BP is 120/80)
Then compare values at left lateral and immediately supine
◦ Implication Positive Roll-over test if there is an: Increase in SYSTOLIC BP of 30 mmHg Increase in DIASTOLIC BP of 15 mmHg
Base line BP = Left Lateral BP Supine BP Difference
100/60 = 90/60 = 120/80 = 30/20
Therefore, this is positive for roll-over test Either systolic or diastolic, positive is positive Therefore, client has increased chance of developing Pregnancy Induced Hypertension
TRIAD OF PREGNANCY INDUCED HYPERTENSION Hypertension after twentieth (20th) week of Age of Gestation Proteinuria
◦ Greater than two-hundred fifty milligrams per deciliter (>250 mg/dl)
Edema
◦ Pathologic ◦ Physiologic
Two (2) General Classifications Pre-eclampsia Eclampsia PRE-ECLAMPSIA Mild Severe
Mild Pre-eclampsia Blood Pressure
◦ Positive to roll-over test ◦ But blood pressure can go as high as 140/90 to 150/100
Proteinuria
◦ Level of protein in urine is 500 mg/dl
Edema No associated signs and symptoms
Management of Mild Pre-eclampsia Bed Rest
◦ To conserve oxygen ◦ Due to constriction of vessels
Limit intake of salty foods ◦ Up to three (3) grams per day
Closer follow-up ◦ Weekly check-up
Severe Pre-eclampsia Blood Pressure
◦ 160/110 or more
Proteinuria Five (5) grams per liter Measured in twenty-four (24) hour urine output
Edema Other signs and symptoms:
◦ Severe headache ◦ Blurring vision due to retention of water going up to optic discs ◦ Fundoscopic examination Looking for papilledema
◦ Pulmonary edema Crackles Cough
◦ Oliguria Urine Output Less than four-hundred milliliters (< 400 ml) in a day Less than thirty thirty milliliters (< 30 ml) in an hour
◦ Epigastric pain Aura of an impending seizure
◦ Reason for Presence of Epigastric Pain Distention of capsule of liver due to edema Necrosis of pancreas Enzymes release digesting contents of intestine
◦ Vomiting
Due to increased intracranial pressure (▲ICP)
Management of Severe Pre-eclampsia Prevention of seizures
PHARMACOLOGIC MANAGEMENT Give Magnesium Sulfate (MgSO4)
◦ Drug of choice ◦ Can also cause decrease in Blood Pressure ◦ (Hydralazine is drug of choice for hypertension)
◦ Check deep tendon reflex ◦ Knee jerk If no reflex, hold magnesium sulfate Hyporeflexia
◦ Magnesium sulfate causes depression
◦ Check Respiratory Rate If less than twelve (12) to fourteen (14) respirations per minute, HOLD Magnesium sulfate causes INCREASED RESPIRATORY DEPRESSION
◦ Check Urine Output Magnesium Sulfate is eliminated through the urine
If urine output is low, Magnesium sulfate cannot be eliminated Loading Dose of Magnesium Sulfate Fourteen grams (14 g)
Four grams (4 g) via I.V. infusion pump Given for a duration of thirty (30) minutes This is painful to the blood vessels
Ten grams (10 g) via I.M. injection Five grams (5 g) on each buttock / gluteus
◦ Maintenance Dose Give at one to two grams (1 – 2 g) in one to two hours (1 hr. – 2 hrs.) Given via I.V. drip Continue forty-eight (48) hours after delivery Because there is post partum pre-eclampsia
◦ Antidote Calcium Gluconate One gram (1 g) via direct I.V.
Provide dim light room Limit Visitors Put up side rails Suction machine by bedside Don’t put anything in mouth if there is seizure Open collar Turn patient to side to eliminate saliva Concern is safety
ECLAMPSIA Positive for seizures Give additional medications:
◦ Diuretics Furosemide is the drug of choice
◦ Digitalis (digoxin) To promote contractility of heart without increasing heart rate Inotropic
Check pulse rate
◦ In Adults: If pulse rate is less than sixty beats per minute (< 60 BPM) – HOLD THE MEDICATION
◦ In children less than ten (10) years old
If pulse rate is less than eighty beats per minute
(< 80 BPM) – HOLD THE MEDICATION In both cases, patient will go into BRADYCARDIA IF MEDICATION IS NOT WITHHELD
◦ Potassium (K+) Prevents DIGITALIS TOXICITY
And USE OF POTASSIUM WASTING FUROSEMIDE
Before giving Potassium (K+) ◦ Before I.V. is in the vein, test for backflow ◦ Subcutaneous tissue necrosis ◦ Tissues get burned due to Potassium (K+)
Barbiturates Fast acting sedatives To arrest seizure Hydralazine For hypertension
HELLP SYNDROME HEMOLYSIS, ELEVATED LIVER ENZYMES, LOW PLATELET Due to necrosis of the liver Disseminated Intravascular Coagulopathy Because of increased pressure in the blood vessels
GESTATIONAL DIABETIS MELLITUS Two (2) values elevated in OGTT
DIET
◦ Maintain daily calorie intake of 1,800 to 2,200 kcal/day ◦ Refrain from eating simple sugars and saturated fats
EXERCISE
◦ Appropriate for Age of Gestation
PHARMACOLOGIC THERAPY ◦ Insulin
Drug of Choice
◦ Oral hypoglycemic agent is teratogenic
Insulin given is based on the weight of the client If client is sixty kilograms (60 kg)
◦ Give 1ų / kg / day ◦ Therefore, give sixty units
In a B.I.D. dosing ◦ Bigger portion is given in the morning ◦ 2/3 of 60 units = 40 units
Smaller portion is given in the evening ◦ 1/3 of 60 units = 20 units
The bigger portion – 2/3 portion or 40 units is composed of ◦ Regular Insulin Brief onset For immediate need Thirty (30) minutes to one (1) hour onset of action
Comprises 1/3 of 40 units
◦ Intermediate Insulin For later need Comprises 2/3 of the 40 units
Note: The bigger portion is given thirty (30) minutes prior to breakfast
For the smaller portion – 1/3 portion or 20 units ◦ 1 : 1 ratio of the regular : intermediate for 20 units 10 units for regular 10 units for intermediate
In drawing insulin Vacuum air First introduced to regular (clear)
◦ Draw this first
Then draw on the intermediate type
Hypoglycemia causes COMA
HEART DISEASE IN PREGNANCY Four (4) Functional Classifications of Heart Disease Class I
◦ Heart Disease is present ◦ But uncompromised
Class II
◦ Heart Disease is present ◦ Slightly compromised
Class III ◦ Heart Disease is present ◦ Markedly compromised
Class IV ◦ Heart Disease is present
Severely compromised
If you belong to Class I and Class II ◦ You can go through normal pregnancy
If you belong to Class III and Class IV ◦ You cannot go through normal pregnancy ◦ You are not a good candidate
In Heart Disease In Pregnancy Labor and delivery should be: Effortless Painless Pushless
◦ A vaginal delivery
EPIDURAL ANESTHESIA Upon active labor (3 cm) Check Blood Pressure Side effect is hypotension
No Oxytocin No Methergine No augmentation of labor All natural labor
General Anesthesia only given when crowning occurs ◦ If given early, this crosses the placenta and the effect is a decrease in the APGAR SCORE
POSITION OF CHOICE DURING LABOR Will deliver at these positions: Semi-sitting Semi-Fowler’s position ◦ Not lithotomy
Femoral vessels are obstructed
DELIVERY OF CHOICE Outlet forceps extraction – Vaginal In Caesarian Section
◦ Normal blood loss is 800 – 1,000 ml ◦ 1,000 ml blood loss is hemorrhage
In Normal Spontaneous Delivery ◦ Normal blood loss is 500 ml
500 ml blood loss is hemorrhag
PUERPERIUM Main Responsibility
◦ Achieve INVOLUTION Return of reproductive organs to pre-pregnancy state
Usually achieved after six (6) weeks
PRINCIPLES 1. PROMOTE HEALING Uterus
◦ At level of umbilicus ◦ After the delivery of the placenta
One (1) day after ◦ One (1) finger breadth below the umbilicus
Two (2) days after ◦ Two (2) finger breadths below the umbilicus
Three (3) days after ◦ Three (3) finger breadths below the umbilicus
Four (4) days after ◦ Four (4) finger breadths below the umbilicus
Five (5) days after ◦ Five (5) finger breadths below the umbilicus
Six (6) days after ◦ Six (6) finger breadths below the umbilicus
Seven (7) days after ◦ Seven (7) finger breadths below the umbilicus
Eight (8) days after ◦ Eight (8) finger breadths below the umbilicus
Nine (9) days after ◦ Nine (9) finger breadths below the umbilicus
Ten (10) days after ◦ Ten (10) finger breadths below the umbilicus or at the level of the symphysis pubis
Eleven (11) days after - Uterus at the pelvic cavity
After six (6) weeks, upon Internal Examination. . . ◦ If Uterus is midway between the umbilicus and symphysis pubis, this is ABNORMAL This means that there is something left inside
SUB-INVOLUTION or POST PARTUM HEMORRHAGE Uterus has not gone back to original size Caused by retained placental fragment
Rubra Day one (1) to day three (3) Day two (2) to day three (3) Bright red in color Serosa Day three (3) to day ten (10) Pinkish in color Actually, brown in color
Alba Day ten (10) until third (3rd) week up to sixth (6th) week post-partum
After six (6) weeks, THERE IS NO MORE LOCHIA
CHARACTERISTICS OF NORMAL LOCHIA Normal Odor
◦ Musty but not FOUL SMELLING ◦ Foul smell indicates infection
Color ◦ Should not be YELLOWISH ◦ Yellowish color indicates infection
Order of Appearance ◦ Should never be reversed ◦ Reversal in appearance indicates RETAINED PLACENTAL FRAGMENTS
LACTATIONAL AMENORRHEA Lactating Fully Not ovulating Six (6) months effectivity
TO BE EFFECTIVE There must be complete emptying of the breast without supplementation (baby receives no bottle feeding) Four (4) to six (6) months Start Supplementation
Normally, after eight (8) weeks or two (2) months, MENSTRUATION RETURNS If the mother is breastfeeding, it would take six (6) months BEFORE MENSTRUATION RETURNS
After three (3) to four (4) weeks, COITUS IS ALLOWABLE
2. PROVIDE EMOTIONAL SUPPORT TAKING IN First two (2) days post-partum Mother is very dependent for care for self and the newborn Rejecting rooming-in is NORMAL
TAKING HOLD After second day
◦ Mother is now independent of self care and newborn care ◦ Time of evidence of POST PARTUM BLUES / DEPRESSION IS OVERT
◦ If poor support system is present, this predisposes to POST PARTUM BLUES / DEPRESSION / PSYCHOSIS ◦ Brief Psychotic episode lasts for three (3) months
LETTING GO Completely accepted role as a new mother
3. PREVENTION OF POST-PARTUM. . . 3.1) MATERNAL HEMORRHAGE Early post-partum hemorrhage Occurs within the first twenty-four (24) hours after delivery
Uterine atony is most common cause Lacerations are the second most common cause Inherent clotting disorders occur: Thrombocytopenia Leukopenia
Late post-partum hemorrhage ◦ Occurs after first twenty-four hours of delivery
Common causes: ◦ Primary Cause Retained placental fragment/s
◦ Secondary Cause Hematoma (vaginal)
3.2) INFECTION Endogenous infection Normal flora causes infection These travel up the uterus
3.3) PERINEAL INFECTION On site of episiotomy
◦ Management involves antibiotic therapy
Surgical Management ◦ Remove suture ◦ Drain pus
Position in Semi-Fowler’s position
3.4) ENDOMETRITIS Infection of the lining of the uterus
◦ With maternal fever > 38° C (37.5°C is common due to dehydration) ◦ With foul-smelling vaginal discharge
With uterine or abdominal tenderness
Management for Endometritis Antibiotics Position
◦ Semi-Fowler’s position
Oxytocin is given ◦ Promotes contractions ◦ Promotes release of secretion
ENDOMETRITIS is a PRELUDE to THROMBOPHLEBITIS
3.5) THROMBOPHLEBITIS Most common site are the vessels of the LOWER EXTREMITIES Positive (+) for HOMAN’S SIGN
How is Homan’s Sign elicited? ◦ Ask patient to dorsiflex foot ◦ Upon lying supine, legs extended ◦ Stretching of the blood vessels causes pain on calf muscle (gastrocnemius muscle)
Management of Thrombophlebitis ◦ Antibiotics ◦ Anticoagulant Heparin Larger molecule than warfarin Less likely to enter breast milk
Discontinue breastfeeding whether heparin or warfarin is administered Antidotes
◦ For Heparin Protamine Sulfate
◦ For Warfarin Vitamin K
ESTABLISHMENT OF SUCCESSFUL LACTATION La leche Method
◦ When placenta is delivered ◦ There is decreased estrogen and progesterone
This indicates production of PROLACTIN
◦ Stimulation of acinar cells to produce milk and stored in the lobules ◦ Upon sucking, OXYTOCIN IS RELEASED This is the hormone responsible for the EJECTION OF MILK
HOW TO BREASTFEED Offer entire breast up to the areola Assume side lying position Hype up to suck whole nipple and areola Pull breast tissue away from the NOSE of the baby
Day 1 Start breastfeeding for five (5) minutes on each breast Day 2 Provide breastfeeding for six (6) minutes on each breast
Day 3 Provide breastfeeding for seven (7) minutes on each breast Day 4 Provide breastfeeding for eight (8) minutes on each breast
Day 5 Provide breastfeeding for nine (9) minutes on each breast Day 6 Provide breastfeeding for ten (10) minutes on each breast Stop and maintain ten (10) minute feeding per breast This would give a total of twenty (20) minutes of breastfeeding time
Important Concept! Breastfeeding is done on a per demand basis
1. CARDIOVASCULAR SYSTEM HEART As diaphragm rises, the heart is displaced laterally
Point of Maximum Impulse ◦ Normally located at Fifth Intercostal Space Midclavicular Line on the Left Side {5th ICS-MCL (L)} ◦ This shifts to Fourth Intercostal Space Lateral Axillary Line on the Left Side {4th ICS-LAL (L)}
◦ Exaggeration of first and second heart sounds {S1 (Lub) and S2 (Dub)} due to INCREASED CARDIAC OUTPUT
Appreciation of S3 (third heart sound; ventricular filling) due to INCREASED CARDIAC OUTPUT
Appreciation of a MURMUR, which is almost always SYSTOLIC (all pathologic) in natureInnocent in nature ◦ As soon as mother delivers placenta, excess fluid is absorbed or excreted, then the MURMUR DISAPPEARS
Blood Volume is INCREASED due to INCREASE IN WATER RETENTION
HIGHEST CARDIAC OUTPUT IN PREGNANCY Twenty-eight to thirty-two weeks (28-32 wks) Age of Gestation During labor and delivery Immediately postpartum Therefore, be careful and monitor pregnant cardiac patient
Supine Hypotensive Syndrome ◦ When mother assumes supine position, she develops hypotension ◦ Weight of uterus presses on the VENA CAVA This results into DECREASED VENOUS RETURN This results into DECREASED CARDIAC OUTPUT End result is HYPOTENSION
Therefore, SUPINE POSITION IN PREGNANCY IS NOT ALLOWABLE (particularly in the second and third trimester)
POSITION OF CHOICE ◦ Side-lying Left (so as not to impede the Vena Cava ◦ Left Lateral Position ◦ Sim’s Left Position With arm flexed Leg flexed Weight of uterus would be ON THE BED
2. HEMATOLOGIC CHANGES HEMODILUTION Due to increase in PLASMA VOLUME
CHANGES IN PLATELET Expected during Postpartum Due to blood loss, there is TRANSIENT INCREASE IN PLATELET COUNT This predisposes to THROMBOSIS due to platelet aggregation This would then predispose to EMBOLISM
Therefore, EARLY AMBULATION is NEEDED
WHITE BLOOD CELL LEVELS INCREASE (particularly in labor) LEUKOCYTOSIS is STRESS-INDUCED
◦ Increased by 20K to 30K
Therefore, DO NOT CORRELATE THIS TO INFECTION NO FEVER NO abdominal / uterine infection
3. RESPIRATORY SYSTEM Diaphragm is prevented from descending in inspiration on second and third trimester Tidal Volume is increased
◦ Lungs are easily filled ◦ Client tends to hyperventilate ◦ Therefore, RESPIRATORY ALKALOSIS OCCURS
This is manifested by: ◦ Tingling sensation on the lower ends of extremities ◦ Lightheadedness
Nursing Management ◦ Breathe through a paper bag or through cupped hands
During labor, there is increase in oxygen consumption by three-hundred percent (300%) ◦ When exhaling, pursed lip breathing is practiced during labor
Swelling of mucosa during estrogen ◦ Prone to epistaxis ◦ Therefore, caution in picking nose!
4. GASTROINTESTINAL TRACT 4.1) PICA Craving for food Unedible (i.e. rice grains) No reason for this May be due to hypersalivation If not checked, this causes vomiting
4.2) EPULIS OF PREGNANCY Effect on gums Swelling of gums due to INCREASED ESTROGEN
Therefore, CONTINUE TO USE SOFT BRISTLE TOOTHBRUSH
4.3) ESOPHAGUS Progesterone is a relaxant of smooth muscle
◦ Effect is on lower esophageal sphincter ◦ It is more relaxed
Pressure of Lower Esophageal Sphincter (LES) is less than pressure on Cardiac Sphincter (CS) ◦ If LES pressure is > CS pressure No regurgitation
◦ If LES pressure is < CS pressure ◦ There is HEARTBURN OR PYROSIS; SUBSTERNAL PAIN related to eating
Most common surgical complication of pregnancy is ACUTE APPENDICITIS! Right Upper Quadrant pain is not expressed during pregnancy or on flank as the appendix rises in pregnancy
Nursing Management Do not assume supine position after eating Gradual ambulation Small Frequent feeding
Due Progesterone’s relaxing effect on smooth muscles, there IS INCREASED GASTRIC EMPTYING TIME ◦ Water and electrolytes absorbed by walls ◦ This gives rise to hard stools ◦ This eventually leads to constipation
Management ◦ Increase fluid intake ◦ Provide high fiber diet
Tendency is to do valsalva maneuver ◦ This leads to hemorrhoids
Progesterone also decreases stretchability of vessels. ◦ This also causes hemorrhoids
5. RENAL OR EXCRETORY SYSTEM 5.1) Due to Progesterone There is relaxation of renal pelvis and the ureter
Therefore, URINE STAGNATION occurs in the URETER (no longer peristaltic)
Therefore, the PATIENT IS PRONE TO URINARY TRACT INFECTION
5.2) Glomerular Filtration Rate in Pregnancy Increased Cardiac Output Increased Glomerular Filtration Rate But absorptive capacity of nephrons is not increased (NO CHANGE IN ABSORPTION)
Therefore, the following will be spilled in the urine: ◦ Sugar ◦ Carbohydrates ◦ Protein
Carbohydrates in the urine is NORMAL Acceptable level of Carbohydrates in the urine
◦ Qualitative analysis ◦ Trace = +1 sugar
Protein in the urine is NORMAL Acceptable level of Proteins in the urine
◦ Trace = +1 Protein ◦ Or less than 250 mg / dl
If Protein level in the urine is greater than 250 mg / dl, CONSIDER PREGNANCY INDUCED HYPERTENSION
If you LOSE PROTEIN and RETAIN WATER, this leads to EDEMA ◦ This is Physiologic Edema ◦ This type of edema is normal and expected in pregnancy
No management for PHYSIOLOGIC EDEMA ◦ Supportive ◦ Leg raises
For Pathologic Edema ◦ Identify the cause of the edema ◦ Most common cause is PREGNANCY INDUCED HYPERTENSION
6. ENDOCRINE SYSTEM Hypertrophy is present in most of the endocrine system organs Thyroid Gland is hyperthrophied Increased production of thyroid hormones
Therefore, there is RISK FOR HYPERTHYROIDISM
◦ Patient may die when in labor with hyperthyroidism ◦ Thyroid Storm leads to arrhythmia ◦ Arrhythmia leads to DEATH
Therefore, monitor so that client goes EUTHYROID (with normal thyroid hormonal level)
7. NEUROLOGIC SYSTEM This is the only system UNAFFECTED during pregnancy The following are normal during pregnancy:
◦ Blurring of vision
Headache
8. MUSCULOSKELETAL SYSTEM 8.1) PLACENTA IS CAPABLE OF PRODUCING RELAXIN Relaxes pelvic joints Therefore, the pelvis is more movable
8.2) DIASTASIS RECTI Separation of rectus abdominis muscle Only fascia remains in between This is normal Rectus abdominis muscle goes back after pregnancy (coarctate)
8.3) PHYSIOLOGIC LORDOSIS Known as the PRIDE OF PREGNANCY Increased outward curvature
◦ There is back pain
Nursing Management ◦ Do PELVIC ROCKING Place direct pressure on lumbar area
◦ Prevent supine position Increases pressure on the spine
◦ No analgesics
FETAL CIRCULATION PLACENTA Functions of the Placenta Mnemonic is NIMEE N is for: NUTRITION or NIDATION
◦ Supplying nutritional requirements of the fetus
◦ Nutrients and oxygen exchanged ◦ THE BLOOD IS NOT EXCHANGED ◦ Modes of Exchange Active transport from mother to baby Diffusion Pinocytosis
I is for: IMMUNOLOGIC ◦ If not pregnant, all foreign matter – antigens are rejected ◦ Baby is a foreign matter ◦ But immunologic function of the placenta removes the MAJOR HISTOCOMPANITIBILITY COMPLEX TYPE 2 (MHC TYPE 2) ◦ This is responsible for rejecting the foreign body
M is for: METABOLIC FUNCTION ◦ In Fetal Circulation Nutrient exchange occurs NO PORTAL CIRCULATION EXISTS Liver is bypassed as METABOLISM (by the liver) is NOT NEEDED
E is for: ENDOCRINOLOGIC ◦ Hormones are secreted only during pregnancy: Human Placental Lactogen Human Chorionic Gonadotropin Relaxin
E is for: EXCRETORY Metabolites excreted by Placenta and NOT BY THE KIDNEY NOR THE LIVER
FETAL CIRCULATION Starts from the placenta Connected to the uterus Decidua is bathed by UTERINE ARTERY Uterine Artery ► Sinuses of the Placenta ►Exchange of nutrients ►Umbilical vein
Placenta ▼▼▼ Umbilical vein (composed of two arteries and one vein – AVA) ▼▼▼ Liver ▼▼▼ Ductus Venosus (First Shunt)
▼▼▼ Inferior Vena Cava ▼▼▼ Right Atrium ▼▼▼ Foramen Ovale (Second Shunt) ▼▼▼ Left Atrium ▼▼▼ Left Ventricle
▼▼▼ Aorta ▼▼▼ ▼▼▼ To upper half of the fetal body only Upper Extreme Brain Heart Pulmonary
Upper part of the GUT ▼▼▼ ▼▼▼ Then this blood is recollected ▼▼▼ with less oxygen and then it ▼▼▼ goes to the ▼▼▼ Superior Vena Cava
▼▼▼ Right Atrium ▼▼▼ Right Ventricle ▼▼▼ Pulmonary Artery (but lungs are collapsed; Surfactant inadequate and amniotic fluid is present) ▼▼▼ Ductus Arteriosus
▼▼▼ Descending Aorta ▼▼▼ Supply the lower half of the fetal body ▼▼▼ ▼▼▼ Blood is recollected ▼▼▼ Hypogastric Artery ▼▼▼ Umbilical Artery ▼▼▼ Placenta
SHUNTS When the baby is delivered, the shunts are normally removed ◦ Ductus Venosus ◦ Foramen ovale
Two (2) types of Closure Functional Closure Anatomic Closure
FORAMEN OVALE Closed functionally immediately after birth or IMMEDIATELY AFTER CORD IS CLAMPED Anatomically, it can persist up to one (1) year after delivery
◦ Therefore, in auscultation in twenty-eight (28) day old baby There is a MURMUR This is Normal This is NOT A PATHOLOGIC MURMUR It is a SYSTEMIC / INNOCENT MURMUR
◦ A PHYSIOLOGIC MURMUR IN NEONATES
DUCTUS ARTERIOSUS Functional Closure ◦ Ten to ninety-six hours (10 – 96 hrs) after birth or approximately four (4) days
Anatomically ◦ Two to three months (2 – 3 mos.)
DRUGS TAKEN DURING PREGNANCY NSAIDs Indomethacin ◦ Not advisable ◦ Causes premature closure of the Ductus Arteriosus ◦ Not compatible with life ◦ No supply to the lower half of the body of the fetus PARACETAMOL IS ALLOWED
ASPIRIN Causes persistence of Ductus Arteriosus even after delivery No functional / anatomic delivery of Ductus Arteriosus Important Concept!
◦ Stop taking about four (4) weeks prior to confinement
ASSESSMENT OF FETAL MATURITY AND WELL-BEING 1. MATERNAL HISTORY AND PHYSICAL EXAMINATION 1.1) First thing to ask is the LAST MENSTRUAL PERIOD Purpose is to IDENTIFY THE AGE OF GESTATION
1.2) What are History of Previous Pregnancy: NSAID? Postpartum complication? Infection?
1.3) Past Medical History Diabetes Mellitus? Gestational Diabetes? Hypertension?
2. FETAL HEART TONE Easiest method to assess for fetal wellbeing Very reliable indicator of oxygenation of the fetus If FHT is heard
◦ Fetus is alive ◦ THIS IS AN ALL OR NONE RESPONSE
NORMAL
◦ 120 –160 beats per minute
If greater than 160 ◦ Tachycardia
If less than 120 ◦ Bradycardia
Be able to assess that sound you hear in the mother is the FHT In the mother’s abdomen, you can hear:
◦ BORBORYGMIC SOUNDS
Hunger sounds
◦ UMBILICAL SOUFFLE When the blood in the placenta enters the umbilical vein, this coincides with the Fetal Heart Tone
But FHT should be DISTINCT
Fetal Heart Tone sound TUG – TUG – TUG
Umbilical Souffle Sound SHHH – SHHH – SHHH This is the sound of the gush of blood
◦ UTERINE SOUFFLE Sound heard when blood enters uterine artery This coincides with the heartbeat of the mother
IDEAL WAY TO TAKE THE FETAL HEART TONE Use the bell of the stethoscope
◦ Purpose is for greater amplification
Hand / Dominant Hand ◦ On area being auscultated
Non-Dominant Hand
◦ Palpates radial pulses for the mother
Therefore, you can correlate ◦ FETAL HEART TONE IS DISTINCT TUG – TUG – TUG – TUG
◦ Radial pulse of the Mother is
Tug - - - - - - Tug - - - - - - Tug
FETAL MOVEMENT Two (2) schools of thought
◦ Cardiff Count to Ten ◦ Sandovsky Method
CARDIFF COUNT TO TEN Normal Fetal Movement
◦ At least one (1) movement every five (5) to six (6) minutes ◦ About ten (10) to twelve (12) movements per hour
First Instruction ◦ Instruct the client to eat LIGHT MEAL one (1) hour before monitoring for fetal movement
Have short walk or massage abdomen as baby may be asleep or is hungry Ask mother to assume left lateral position A clock must be at the bedside with pencil and paper Dominant hand of mother palpates most prominent part of abdomen Note for any fetal movement
FETAL MOVEMENT SHOULD BE ASSESSED WHEN THERE IS QUICKENING (AT TWENTYFOUR MONTHS AGE OF GESTATION ONWARDS)
Mother notes for ten (10) fetal movements and NOTES THE TIME THAT THE TEN (10) FETAL MOVEMENTS HAVE BEEN COMPLETED ◦ Should be completed in one (1) hour ◦ Approximately five (5) movements in thirty (30) minutes
You MUST get at LEAST ONE HALF OF NORMAL
Therefore, AT LEAST FIVE (5) FETAL MOVEMENTS PER HOUR IS ACCEPTABLE
SANDOVSKY METHOD Same procedure as in Cardiff Count to Ten Mother monitors fetal movement three (3) times a day These are done:
◦ After breakfast ◦ After lunch ◦ After dinner
Normal You should appreciate two (2) to three (3) fetal movements in one hour
OTHER WAYS TO ASSESS: DIAGNOSTICS AMNIOCENTESIS Best done at sixteen to eighteen (16 – 18) weeks Age of Gestation or during second (2nd) trimester This is the time when the baby is SMALL and there is MUCH AMNIOTIC FLUID
Information Obtained: A) FETAL LUNG MATURITY Analyzed for lung surfactant: Dipalmytoyl Phosphatidylcholine L : S Ratio
◦ Lecithin : Sphingomyelin Ratio
Lecithin is a specific component of lung surfactant
◦ Lecithin should be greater than Spinglomyelin ◦ Normal Ratio is 2L : 1S
If there is anticipated premature delivery, amniocentesis is done to know if delivery is viable
PHOSPHATIDYL GLYCEROL (PG) Most potent of all lung surfactants Usually appreciated at amniotic fluid at THIRTY-FOUR to THIRTY SIX (34 – 36) WEEKS AGE OF GESTATION
Therefore, it is safe to deliver fetus if Phosphatidyl Glycerol is present There is decreased risk of respiratory distress
POLYHYDRAMNIOS Amniotic fluid greater than 2,000 ml
◦ A teratogenic effect
Therefore, remove part of amniotic fluid
IDENTIFICATION OF GENETIC OR CHROMOSOMAL PROBLEM HOW TO PREPARE THE CLIENT FOR AMNIOCENTESIS
Explain what to do to the client Get Consent Remember, CONSENT IS NEEDED as this procedure is INVASIVE! Client must have I. V. fluid
◦ Plain Normal Saline Solution ◦ Side drip of Tocolytic to relax the uterus
Ask client to void before the procedure so as not to puncture bladder ◦ Ultrasound-guided procedure ◦ Needle should not puncture the placenta
Abdomen is prepared aseptically
Specific Site ◦ Pocket of abdomen containing highest amount of Amniotic Fluid ◦ Done by OBSTETRIC SONOLOGIST
Needle Inserted ◦ Local anesthesia ◦ Abdominal wall through the uterus to amniotic sac
Post Procedure ◦ ◦ ◦ ◦ ◦
Check Vital Signs (every fifteen (15) minutes) Check Blood Pressure Check Fetal Heart Tone Client then rests for two (2) to three (3) hours Mother is then sent home
DISCHARGE INSTRUCTIONS ◦ Note for UTERINE TONE ◦ Note for Fetal Activity ◦ Client may be: Hyperactive In distress
Hypoactive In distress
◦ Note for vaginal bleeding or spotting ◦ Vaginal spotting is acceptable
DANGER SIGNS Persistent uterine contraction Hyper / Hypoactive Vaginal Spotting to Bleeding
◦ Therefore, ask mother to come back if she observes any of the above signs
MATERNAL SERUM ALPHA FETOPROTEIN A special kind of protein produced in the yolk sac of the liver of baby / fetus Specimen is blood Consent is needed
Normal value of Maternal Serum Alpha Feto Protein (MS AFP) ◦ 2.0 – 2.5 MOM (measurements of the mean)
If MS AFP is higher than normal, THERE IS A NEURAL TUBE DEFECT: ◦ Spina bifida ◦ Meningocoel ◦ Myelomeningocoel
Anencephaly
If MS AFP is lower than normal, THERE IS DOWN’S SYNDROME Therefore, you must be able to know exact Age of Gestation
Fifteen to Twenty (15 – 20) weeks Age of Gestation is the IDEAL TIME FOR MS AFP or during the SECOND (2nd) TRIMESTER, not on the First or the Third Trimesters If early high result
◦ Yolk sac and liver gives false elevated result
If late low result
◦ Liver only gives false low result
CHORIONIC VILLUS SAMPLING (CVS) Get part of chorionic villi from the placenta Done at nine to twelve (9 – 12) weeks Age of Gestation Approach is INTRAVAGINAL Ultrasound-guided
A part of chorionic villi near maternal attachment will be suctioned to the catheter for KARYOTYPING and GENETIC ANAL
Purpose of this procedure is for detection of genetic and chromosomal problems Nursing Responsibility
◦ Bleeding is common in CVS ◦ Instruct mother to observe SPOTTING to BLEEDING ◦ Ask mother to come back if bleeding occurs
Therefore, not much done; increases chance of abortion or fetal loss
PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS) Also known as CORDOCENTESIS Get sample Ultrasound-guided Sonologist identifies umbilical vein
◦ Vein has larger lumen than the artery
Catheter is inserted Approach is through the abdomen
Information obtained: ◦ For identification of blood incompatibilities ◦ For exchange transfusion ◦ For isoimmunization Needed in instances of an Rh+ baby and an Rhmother
ULTRASOUND Types of Ultrasound Transabdominal Ultrasound Transvaginal Ultrasound
TRANSABDOMINAL ULTRASOUND Ask the client to FILL BLADDER Full bladder will push uterus to pelvic cavity for better visualization at abdomen
ULTRASOUND IN FIRST TRIMESTER Information obtained: Confirmation of Pregnancy
◦ (+) cardiac movement ◦ (+) yolk sac ◦ (+) Fetal Heart Tone
Identification of Ectopic Pregnancy ◦ Fallopian tube is PERISTALTIC
◦ Therefore, look at the uterus
◦ If the uterus is empty and positive (+) for pregnancy test, then there is pregnancy outside or ECTOPIC PREGNANCY
Identification of Intrauterine Device (IUD) in Place ◦ Intrauterine Device Has 97% protection Has 3% failure rate
◦ If IUD is in place and pregnancy occurs, advice the client to LET THE IUD STAY IN PLACE ◦ IUD will attach to the fetal membrane ◦ If taken out, there is greater chance of SPONTANEOUS ABORTION
Identification of the H-MOLE ◦ Ultrasound characteristic of H-Mole SNOW STORM APPEARANCE In a dark background there is a speck of white
There are vesicles
ULTRASOUND IN THE SECOND AND THIRD TRIMESTER Information obtained: Location of Placenta ◦ Placental Localization
Growth of the Fetus Amount of Amniotic Fluid Fetal Position and Fetal Presentation Sex / Gender of the baby
◦ Determinable at sixteen (16) weeks of gestation ◦ Ideal time is twenty-eight (28) weeks
Congenital / Chromosomal Problems
◦ Determined by three-dimensional (3D) ultrasound
TRANSVAGINAL ULTRASOUND Ask client to void
BIOPHYSICAL SCORE Has five (5) parameters (including NonStress Test or NST) Modified Biophysical Score
◦ Has four parameters only
Uses ULTRASOUND
Criteria / Parameters observed ◦ Fetal Breathing Two (2) is the highest score for this parameter
◦ Fetal Movement Two (2) is the highest score for this parameter
◦ Fetal Muscle Tone Flexion and extension in utero Two (2) is the highest score for this parameter ◦ Amniotic Fluid Index Done for a period of thirty (30) minutes Baby’s breathing is not spontaneous Two (2) is the highest score for this parameter
Perfect score is 8/8
◦ This means that the baby is in the best possible health
Before, Biophysical Score includes the NonStress Test Non-Stress Test
◦ For fetal heart activity ◦ With this parameter added, the perfect score in BPS becomes 10/10
NON-STRESS TEST Uses CARDIOTOGORAPH (CTG) TRACING No stressor on part of the baby
Stressor is the contraction of the uterus There should be NO CONTRACTION Compare
◦ Fetal Heart Tone and Fetal Movement If baby moves, FHT INCREASES!
With two (2) transducers placed near FHT at fundus of uterus Leopold’s maneuver Water soluble lubricant
◦ KY jelly amplifies FHT
CRITERIA TO SAY NST IS NORMAL Period of Observation should be ◦ Greater than or equal to twenty (20) minutes
You must get at least two (2) accelerations in twenty (20) minutes Acceleration should be at least fifteen (15) beats above baseline
Duration of acceleration should be ◦ Greater than or equal to fifteen (15) seconds ◦ One (1) small square = one (1) second
Therefore, IF ALL CRITERIA ARE MET, NONSTRESS TEST IS NORMAL
If NST is NORMAL – IT IS REACTIVE Therefore, the chances of fetal survival is greater than 99% in the next week You can assure the mother
If NOT ALL CRITERIA ARE MET (i.e. Criteria No.3 with 10 beats per minute only), Repeat NST after two (2) to three (3) hours
If NST is NON-REACTIVE, it is ABNORMAL
CONTRACTION STRESS TEST (CST) Best done when mother is at thirty-eight (38) weeks Age of Gestation Done when NST is NON-REACTIVE Then, proceed with Contraction Stress Test If CST could not be withstood by baby, IT NEEDS IMMEDIATE DELIVERY Introduce a STRESSOR – CONTRACTION if ABNORMAL CST
OXYTOCIN CHALLENGE TEST Rub nipples
◦ Nipple stimulation if uterus is NOT contracting
When assessing ◦ Hide your thumb
If you are a male so as not to be sued for sexual harassment
TWO (2) ABSOLUTE CONTRAINDICATIONS FOR CONTRACTION STRESS TEST If client is premature (Biophysical Score is used instead) History of problem in the placenta (placentation)
NIPPLE STIMULATION ◦ Give warm pack / warm soaks for ten (10) minutes prior to stimulation to increase circulation / vascularity ◦ Explain procedure ◦ Start ◦ Four (4) cycles per stimulation ◦ 1, 2, 3, 4 stimulations REST x4
First Cycle
◦ If after these and there are NO CONTRACTIONS ◦ Stop and rest for two (2) to four (4) minutes ◦ Then stimulate Up to four (4) cycles
◦ If NO CONTRACTIONS AFTER THE FOURTH (4th) CYCLE Stop stimulation Proceed with Oxytocin Challenge Test
OXYTOCIN CHALLENGE TEST Give diluted form of oxytocin
◦ Five units (5U) or ½ampule + 1 liter D5LR or D5H2O
Give
at a titrating dose Start at ten to twelve (10-12) drops per minute to a maximum of forty (40) drops per minute Observe for Uterine Contraction
Wait for two (2) consecutive uterine contractions Stop Oxytocin Challenge Test if two (2) uterine contractions are obtained Now compare Uterine Contractions with Fetal Heart Tone
NEGATIVE ◦ In the presence of uterine contraction, tracing is NEGATIVE FOR DECELERATION
Vagus Nerve ◦ Parasympathetic Stimulation gives rise to bradycardia
Carotid Stimulation results into ◦ Bradycardia ◦ Hypotension
Abnormal if POSITIVE (+) FOR DECELERATION
INTERVENTIONS If in labor: Turn client to left lateral position Stop oxytocin immediately ◦ No contractions are wanted
Give oxygen to mother ◦ Rate is 8 – 10 liters per minute
Hydrate with plain water ◦ No incorporation of oxytocin to increase circulating blood volume ◦ Mother is on NPO during labor and there could be DEHYDRATION
ADH secretion is increased to conserve water ◦ ADH is released from the posterior pituitary ◦ Oxytocin is released from the posterior pituitary ◦ Cross reaction of ADH and Oxytocin in the Uterus ◦ ADH binds in OXYTOCIN RECEPTORS in Uterus resulting to CONTRACTION ◦ Therefore, hydrate so as not to increase ADH secretion
If variable deceleration is >10 minutes, then CAESARIAN SECTION may be NECESSARY
LATE DECELERATION Occurs before contraction ends Has a late recovery Baseline is changed Lower than original baseline Significance: ◦ UTEROPLACENTAL INSUFFICIENCY is present
Management ◦ Hydrate ◦ Give oxygen ◦ Stop oxytocin
Placenta and Uterus are compromised ◦ Therefore, this is an indication for OUTRIGHT ABDOMINAL DELIVERY ◦ Do outright Caesarian Section
PRE-NATAL ASSESSMENT In the Ideal Setting: At zero to twenty-eight weeks (0 – 28) Age of Gestation
◦ Ask client to come back every four (4) weeks
At twenty-eight to thirty-six weeks (28 – 36) Age of Gestation ◦ Ask client to come back every two (2) weeks
At thirty-six (36) weeks onwards Ask client to come back every week
DOH RECOMMENDATION One (1) pre-natal check-up per TRIMESTER Three (3) pre-natal check-ups during the entire course of pregnancy
If high risk Below 18 years old Above 35 years old Greater than Gravida 5
◦ Due to higher chances of maternal bleeding after delivery
Problem in placentation (location)
History of Maternal illness ◦ Hypertension ◦ Diabetes mellitus ◦ Cardiac Problems
Clinical check-up should be performed every week!
Auscultate the lungs on the first visit Nursing history has physical examination
◦ ◦ ◦ ◦
This is done by the nurses Not weigh Baby is sleeping contentedly Baby will cry
Changes in heart rate NO IPPA IN PEDIATRIC PATIENTS
Get Maternal History of Client Laboratory Examinations COMPLETE BLOOD COUNT Hemoglobin Hematocrit Platelet Rh and ABO blood typing
Important Concepts! Asians NOT COMMONLY Rh Caucasians are COMMONLY Rh
BLOOD NOMENCLATURE ABO Typing ◦ Type A, B, O ◦ A or B antigens
Rh Typing ◦ Rh (C, D, E) ◦ Three antigens C D E
◦ In incompatibility, the concern is the D antigen
Rh Mother is RhFather is Rh+ No D antigens ▼▼▼ Rh- or Rh0 ▼▼▼ (zero for D) ▼▼▼ ▼▼▼▼▼▼▼▼▼▼▼▼▼ Baby is Rh+ or Rh(D) Antigen D is present in the blood
The first pregnancy is spared The first baby is born Blood enters mother’s circulation
Therefore, mother PRODUCES ANTI-D antibody
Interaction During time of delivery when the placenta starts to detach from maternal attachment Abortion / Dilatation and Curettage Some fragments of placenta are retained in the uterus Ancillary Procedures like AMNIOCENTESIS Interaction of blood of baby entering mother occurs and stimulates antigenantibody reaction
Second Pregnancy Anti-D antibody of mother hemolyzes the Antigen D of second baby
◦ This results into erythroblastosis fetalis or death of the RED BLOOD CELLS ◦ Second baby would have SEVERE ANEMIA ► HEART FAILURE ►ANASARCOUS►DEATH
RHOGAM Gamma globulin A pre-formed antibody Given within seventy-two (72) hours If to undergo amniocentesis
◦ Rhogam is given before the procedure
If mother undergoes abortion ◦ Rhogam is given within seventy-two (72) hours after abortion
If pregnant now
◦ Give at twenty-eight to thirty-two (28 – 32) weeks Age of Gestation ◦ to Rh- mother REGARDLESS OF Rh of Baby
RhoGam
is repeated prior to term at forty (40) weeks RhoGam has a half life Rhogam may be out of circulation
COOMB’S TEST Two (2) types Direct Coomb’s Test Indirect Coomb’s Test
DIRECT COOMB’S TEST Concerns the Baby Identify if RBC of baby has hemolysis and has attached antibody Therefore, sensitization has occurred on the mother
INDIRECT COOMB’S TEST Concerns the mother Identify for titer of antibody
◦ ◦ ◦ ◦
Get blood sample Identify titer of Anti-D Zero titer if Rh+ If Rh- individual 1 : 8 or 1 : 16
If titer is less than 1 : 8 this means that MOTHER IS NOT YET SENSITIZED ◦ Therefore, blood of the mother is FREE OF ANTI-D antibody
There is a need for RhoGam
If
titer is greater than 1 : 16 this means that there is SENSITIZATION ◦ It has ANTI-D antibody ◦ Then, RhoGam is NOT needed ◦ RhoGam CANNOT REVERSE SENSITIZATION
Situation Mother is Type O Rh Baby is Type A Rh+
Question What type of blood do you give?
Answer Give type A blood
Rationale Hemolysis is present Baby has anti-D that is why there is hemolysis If Rh+ is given
◦ There is continuous antibody given – there is confirmed hemolysis ◦ Therefore, give Rh-
ALWAYS GIVE THE BLOOD TYPE OF THE MOTHER (as far as Rh is concerned)
If mother is Rh+ and father is Rh+, then the baby is Rh+ and there is no problem
Type O blood causes hemolysis If baby is type A, B, AB
Question What type of blood in mother will cause hemolysis in ABO? Answer Type O Question What type of blood will be given to the baby if there is ABO incompatibility? Answer Blood type of mother
Most common cause of PATHOLOGIC JAUNDICE is ABO INCOMPATIBILITY Pathologic Jaundice is prolonged jaundice Normal Value of Bilirubin
◦ 15 mg / dl
If greater than 15 mg / dl, transformation is needed ABO INCOMPATIBILITY is protective against Rh INCOMPATIBILITY
◦ If Mother is type O
◦ If Baby is type A
RBC carries Rh(D) ◦ RBC of baby contains D antigen ◦ Since hemolysis has already occurred, Anti-D of mother will no longer hemolyze any RBC with Anti-D
APGAR – SCORING SIGN
O
1
2
HR
absent
<100
>100
Respirator effort
absent
Slow and irregular
Good and strong, loud cry
Some flexion of extremities
Active motion. General flexion
Activity: flaccid muscle tone Reflex irritability
No response to Weak cry or stimuli grimace
Cry: vigorous
appearance
Blue, pale
Completely pink
Body pink, extremities
Fetal anatomy and physiology 1. Fetal circulation – four intrauterine structures that differ from extrauterine structures. a. umbilical vein – carries oxygen and nutrient-enriched blood from placenta to ductus and liver. b. ductus venosus – connects to inferior vena cava; allows most blood to bypass liver.
c.Foramen ovale – allows fetal blood to bypass fetal lungs by shunting it from right atrium into left atrium. d. Ductus arteriosus – allows fetal blood to bypass fetal lungs by shunting it from pulmonary artery into aorta. e. Umbilical arteries – allows return of deoxygenated blood to the placenta.
2. Umbilical cord – extends from fetus to center of placenta: usually 50 cm (18-22 inches) long and 1-2 cm (1/2 – 1 inch) in diameter. Contains: a. Wharton’s jelly – protects umbilical vessels from pressure, cord “kinking” and interference with fetal-placental circulation. b. umbilical vein – carries oxygen and nutrients from placenta to fetus.
c. Two umbilical arteries – carry deoxygenated blood and fetal wastes from fetus to placenta. *absences of one artery indicates need to rule out intraabdominal anomalies.
3. Characteristics of fetal blood b. Fetal hemoglobin (HbF) a.1 higher oxygen-carrying capacity than adult hemoglobin a.2 releases oxygen easily to fetal tissues a.3 ensures high fetal oxygen a.4 normal range at term: 85ml/kg body wt. Hct: 38%-62%, average 53%: RBC 3-7 million, average 4.9 million/U.
Extrauterine adaptation: task 2. Establish and maintain ventilation, successful gas transfer- requires patent airway and adequate pulmonary surfactant. 3. Modify circulatory patterns – requires closure of fetal structures. 4. Absorb and utilize fluids and nutrients 5. Excrete body wastes 6. Establish and maintain thermal stability
A.
Admission assessment of normal, termneonate 1. color and reactivity 2. general appearance, symmetry 3. length and weight 4. head and chest circumferences 5. vital signs:
Criterion Vital signs
Average values
Heart rate
120-140/min, irregular, especially when crying, and functional murmur
respiratory
30-60/min with short periods of apnea, irregular; vigorous and loud cry.
temperature
Stabilizes about 8-10 hr after birth; 36.5 -37 degree centigrade
Blood pressure
60-80/40-50; varies with change in activity level
Criterion
Average values
Measurements weight
3400g(71/2 lbs); range: 5 lb 8 oz – 8 lbs 13 oz
Length
50 cm (20 inches); ranges: 18 – 22 inches
Chest circumference
2 cm (3/4 inch) less than head circumference
Head circumference
33 – 35 cm (13 -14 inches)
Criterion
Average values
General assessment Muscle tone
Good tone and generalized flexion; full range of motion; spontaneous movement
Skin color
Mottling, acrocyanosis, and physiological jaundice; petechiae, milia, mongolian spotting, lanugo, and vernix caseosa
Head
Moulding of fontanels and sutute spaces; one-fourth of body length
Hair
Silky, single strands, lies flat; grows towards face and neck
eyes
Edematous eyelids,
nose
Appears to have no bridge
1.
2.
3.
4. 5.
Altered health maintenance related to separation from maternal support system Impaired skin integrity related to umbilical stumps; incontinence of urine and meconium stool. Ineffective airway clearance related to excessive mucus Pain related to environmental stimuli Ineffective thermoregulation related to immature temperature regulation mechanism
1.
Goal; promote effective gas transport a. maintain patent airway – to promote effective gas exchange and respiratory function. b. Position: right side-lying, head dependent (gravity drainage of fluid, mucus) c. suction prn with syringe for mucus
2. Goal: establish/maintain thermal stability a. Avoid chilling – to prevent metabolic acidosis b. dry, wrap c. place in heated crib d. monitor vital signs hourly until stbale
3. goal: promote bonding. a. encourage parent-infant interaction (holding, touching, eye contact, talking to infant) b. encourage breastfeeding within 1 hr of birth c. encourage parent participation in infant care to develop confidence and competence in caring for newborn
Sleeping – almost continual (wakes only to feed) or 12 – 16 hr daily Feeding – from every 2-3 hr to longer intervals; establish own pattern Weight loss – 5% - 10% in first few days regained in 7-14 days Cord care – drops off in 7 – 10 days Physiologic jaundice – occurs 24- 72 hr after birth. Non pathologic, need for hydration
Age
Bottle-fed
breastfed
implications
1 day
Meconium
Meconium
Absences may indicate obstruction or atresia
2-5 days Greenish yellow, loose
Greenish yellow, loose, frequent
At any time
> 5 days Yellow to brown, firm, 2 -4 daily foul odor
Bright golden yellow, loose, 6 -10 daily
Dairrhea – greenid\sh, mucus Constipation – dry, hard stools
GOOD DAY!
THANK YOU..GOOD LUCK..
1.Which phase of the menstrual cycle is characterized by a surge in luteinizing hormone (LH) from the pituitary gland? A.Proliferative B.Menstruation
C. Ichemic D. Secretory
2. At the beginning of menstruation, the following physiologic changes occurs, except. A. an ovulation begins to mature in the graafian follicle B. estrogen and progesterone are at their lowest level C. luteinizing hormone are at its peak D. follicle stimulating hormone has just begun to rise.
Situation: Mrs. Flor de Luna is on her fifth month of pregnancy.
3Which of the following fetal development has been achieved during the fifth month of gestation? A. ossification of the bone is completed B. Mrs. De Luna can feel her baby’s movement C. Vernix caseosa is developed D. Heartbeat is audible by Doppler
4. When Mrs. De Luna enters the seventh month of pregnancy, how often will be her pre-natal check- up? A. once a week B. as often as she desires D. twice a month
c. once a month
5. What level of the abdomen can be fundic height be palpated at 5 months gestation? A. midpoint between the symphysis pubis B. symphysis pubis C. midpoint between umbilicus and xiphoid D. umbilicus
Situation: Mrs Brenda Mage, 24 year old, consulted at the health center because of nausea and vomiting. She claimed that she missed her menstruation for 2 months and her LMP was March 1.
6. Which of the following is a probable sign that Mrs. Mage is pregnant? absence of menstruation softening of the cervix C. nausea and vomiting D. Breastc hanges
7. Which of the following terms refers to the first pregnancy? A. Primipara B. Nullipara
c. primigravida d. nulligravida
8.How many weeks AOG will Mrs. Mage be on her next prenatal visit, which is scheduled on may 15. A. 13 – 14 B. 12 – 13
C. 10 – 11 D. 11 – 12
9. When will be the EDC of Mrs. Mage? A. December 8 B. December 7
c. December 9 d. January 8
10. Which sign refers to the softening of the lower uterine segment? A. Chadwick’s B. Hegar’s
c. Culkin’s d. Goodel’s
Situation: Nicole claims to be amenorrheic for 1 month. She consults at the lying –in clinic.
11. What hormone is excreted in the urine that serves as the basis for most tests for pregnancy? A. HCG B. FSH
c. progesterone d. estrogen
12. Nicole complains of urinary frequency. Which of the following be the best response of the nurse? A. “ limit your fluid intake to 2 liters per day” B. “ I would not worry if I were you, it is not unusual.” C. “ just use panty shields so you will be dry and comfortable.” D.“ this is expected because of the compression of your ascending uterus.”
13.Which of the following intervention will be the most helpful to Nicole in adapting to her pregnancy? A. encourage her to attend pregnant mothers’ classes B. advise to have a regular pre-natal check-up C. involve her husband in planning for her needs D. assist her in exploring and expressing her feelings
Situation: Marla is 25 year old G2P1, full term is rushed to the ER due to passage of watery vaginal discharge.
14. Which of the following interventions will be the immediate action of the nurse? ◦
take her fetal heart tone c. start an intravenous fluid B. monitor her vital signs d. place her on left lateral position
15. The nurse observes the vaginal discharge of Marla. Which characteristics of the amniotic fluid that the fetus is in distress? volume is about 1 liter c. greenish mucus - tinged d. colorless
16. Which of the following is not a sign of true labor? A. intensity of contractions increases gradually shorten B. intervals between uterine contractions increases C. cervical dilation and effacement increase D. uterine contractions are more frequent and of shorter duration
17.What is the most fatal complication of PROM to the fetus? A. delayed onset of labor B. ascending infection
c. dehydration d. cord prolapsed
18. Marla is instructed to count and record fetal movement every hour. How many movement per hour indicates that Marla’s baby has a healthy status/ A. 2 B. 4
c. 5 d. 3
Situation: Aurora is on her 3rd post normal spontaneous delivery.
19. She complains of inability to defecate inspite of taking regular meals and frequent ambulation. The following are recommended to reestablish her regular defecation, which one is least priority/ A. milk of magnesium 45 ml diet B. adequate fluid intake extraction
c. high roughage d. do manual
20. She must report to the nurse if she observes that her lochial discharge: A. contains mucus and particles of cellular debris B. is bright red on the 5th day post partum C. has a musty odor D.disappears after the third week
21. She remarks, “Do you think I have milk for my baby?” This signals what phase of the puerperium ? A. post partum blues c. taking -hold B. post partum psychosis d. taking –in
22. which of the following will best initiates the secretions of milk? A. use of breast pump in expressing milk B. manual breast expression C. adequate intake of fluid D. allow infant to suck each breast alternately
23.In the physiology of lactation, the oxytocin hormone functions to: A. stimulates lactogenesis c. suppression of milk B. produces more milk d. alters secretion of milk
Situation: Andrea is a newly registered nurse who is assigned at the OB ward where some nursing students are having their related learning experience on the concept of pregnancy.
24. One student asks Andrea to discuss what a zygote is. Her answer will likely be a: A. daughter cell B. cell that results from the fertilization of the ovum by a spermatozoa C. union of an egg by a sperm D. matured ovum
25. Which of the following will best describe mitosis? A. Fertilization of an ovum B. Cell division of the fertilized ovum C. Rupture of the ovum from the graafian follicle D. Implantation of the fertilized egg
26. Andrea discusses how the zygote enters the uterus which usually takes place in how many hours after fertilization? A. 180 hours B.72 hours
c. 48 hours d. 150 hours
27. The mulberry-like ball of cells that results from cleavage is called? A. Blastocyst B. Trophoblast
c. blastomore d. Morula
28. The zygote is normally implanted in what part of the uterus? A. Corpus B. Fundus
c. Cornea d. Cervix
Situation: Lisa, 19 year old single and pregnant for the first time is admitted to the labor room due to the passage of watery vaginal discharge, one hour PTA. I.E revealed 3 – 4 cms. Cervical dilation, 80% effaced, station 0 and (-) BOW.
29. What is the rationale for placing Lisa on complete bed rest upon admission? This will prevent: A. Infection B. Fatigue
c. fetal distress d. cord prolapse
30. Which of the following heartbeats per minute is indicative of fetal distress? A. 159 B. 121
c. 135 d. 165
31. What position is best for Lisa in order to prevent fetal hypoxia? A. left lateral B. dorsal recumbent
c. trendelenburg d. semi- fowlers
32. Which of the following best describes effacement? A. cervix becomes thinner B. presenting part has descended at the level of the ischial spine C. diameter of the presenting part of the fetus has passed through the pelvic inlet D. opening of the cervix becomes wider.
33. Station 0 means that the presenting part of the fetus is: A. still floating B. one centimeter above the ischial spine C. at the level of the ischial spine D. one cm below the ischial spine
Situation: Nurse Jane is assigned at the nursing unit at 6-2 shift.
34. She admitted girl Reyes, full term whose mother has a history of PROM. Jane anticipates that girl Reyes will b; A. Exposed to bili light B. Placed inside the incubator antibiotics
c. given I.V fluids d. given doses of
35. Boy Santoyas, 36 weeks AOG, has cryptorchidism, which refers to: A. undescended testes B. unretracted foreskin of the penis C. ventral location of the urinary meatus D. presence of fluid in the scrotal sac.
36. Girl Pablo develops jaundice. When does physiologic jaundice occur? A. after the 7th day birth B. upon birth
c. twenty four hours after d. between the 2nd and 5th day
37. Boy Malonzo demonstrated a tonic neck reflex, which is described as: A. fanning of the toes when a sharp object is pressed in the sole of his foot B. extension of his leg on the same side to which his head is turned C. turning of the head towards the side of the cheek that was touched. D. Grasping of any object placed in his hand
38. When the crib of girl Liboon is jarred, she develops sudden outward extension of her arms then slowly release. What reflex is this. A. Parachute B. Babinski
c. Landau d. Moro
39. What part of the mother will be the source of nourishment for the baby? A. Uterus c. Amniotic fluid B. Chorionic villi d. placenta
Situation: Janice a community health nurse is attending a home delivery a primigravida client.
40. A probable sign of pregnancy characterized by painless, irregular, abdominal; false labor contractions is called: A. Goodel’s sign c. Braxton Hicks contraction B. Leukorrhea d. Ballotment
41. I. E of 4 cm indicates: A. cervical canal is 4 cm in diameter B. the cervix is 4 cm thick C. the cervical external OS is 4 cm wide D. the cervical internal OS is 4 cm in diameter
42. The meaning of station +1 is: A. the level of ischial spine c. 1 cm below level of ischial spine B. 1 cm above level of ischial spine d. 1 cm above the pelvic inlet
43. It also known as the organ of menstruation. A. Ovaries B. uterus
c. Fallopian tube d. vagina
44. The average lifespan of ovum is: A. 12 hours B. 24 hours
c. 36 hours d. 48 hours
45. The process of implantation takes place in: A. uterus B. ovaries
c. ampulla d. tunica albuginea
46. The non pregnant uterus is lined by the: A. Endometrium c. deciduas vera B.Myometrium d. deciduas capsularis
47. Which terms refers to the externally visible structure of the female reproductive system extending from the symphysis pubis to the perineum? A. mons pubis B. vestible
c. vulva d. labia majora
Situation: Rowena is admitted at the ER with the following findings: Cervical dilation is 6 cm; fully effaced; cephalic presentation; 40 weeks AOG.
48. The nurse observes that Rowena’s abdomen has irregular scar lines as a result of stretching of the skin. This refers to; A. linea negra B. chloasma
c. striae gravidarum d. melasma
49. The obstetrician remarks that the fetus is dipping, which means that the fetus is; A. still floating B. reached the ischial spine C. in station +1 D. descending but has not reached the ischial spine
50. Rowena asks if she can take her meal. What should be the appropriate response of the nurse? A. “ your IV fluid is enough to give you nourishment.” B. “ you can take a light meal” C. “ no, the doctor orders you to be kept NPO” D. “ you cannot take food nor fluids because you are now in active labor.”
1.
b. c. d. e.
If a woman is pregnant for the second time, but her first pregnancy did not reach viability, what would be her parity using the four digit scoring system? 1 –0-0-1 0-0-1-0 0-1-0-00-1-0-1
Answer: B The formula for determining parity is TPAL T- term pregnancies = 38 weeks P- preterm =20-37 weeks A- abortion = pregnancy that do not reach viability 20-22 weeks L – number of living children
2. In providing health teaching for an expectant couple, what should the nurse tell them is a probable sign of pregnancy? c. d. e. f.
Fetal heart sound Positive pregnancy test Fetal movements felt by examiner Outline of fetus on sonogram
Answer: C Positive pregnancy test results are considered among the probable signs of pregnancy.
3. A woman in labor has a history of undiagnosed vaginal bleeding. Which procedure may be contraindicated on her arrival in the labor room? c. d. e. f.
Initiating an intravenous therapy Taking her blood pressure Examining her vaginal canal Monitoring FHR
Answer: C Examining her vaginal canal is contraindicated initially because of her pre admission history of bleeding. The problem may be placenta previa or other bleeding abnormalities in pregnancy.
4. A primipara at term has experience lightening. The nurse should anticipate which sign of discomfort that would normally accompany lightening? c. d. e. f.
Urinary frequency Dyspnea Heartburn constipation
Answer: A Lightening or descent of the fetus puts added pressure on the bladder, causing frequency.
5. A client is in active labor, the baby’s head is crowning, the client is bearing down, and delivery appears imminent. The nurse should: c.
d.
e.
f.
Transfer her immediately by stretcher to the delivery room. Tell her to breath through her mouth and not to bear down Instruct the client to pant during contractions and to breath through her mouth Support the perineum with the hand to prevent tearing and tell the client to pant.
Answer: D Gentle pressure is applied against the baby’s head as it emerges so it is not delivered too rapidly. The head is never held back, and it should be supported as it emerges to prevent a vaginal laceration.
1.
b. c. d. e.
The labor room nurse decides to intervene when the fetal heart rate pattern indicates: A baseline range of 110 to 160 bpm Absence of variability Early deceleration Mild variable deceleration
2. A primipara at term has experienced lightening. The nurse should anticipate which sign of discomfort that would normally accompany lightening. b. Urinary frequency c. Dyspnea d. Heartburn e. constipation
3. A newborn who weighed 7 lbs at birth now weighs 6 lbs 8 oz. Implementing health teaching, the nurse tells the mother the percentage of birth weight usually lost by normal, healthy babies. Which represents the maximum amount of normal weight loss for this newborn? b. 6 oz (170g) c. 8 oz (227g) d. 11 oz (317g) e. 16 0z (454g)
4. Of the following findings in full-term newborn, which is not an expected outcome of maternal hormone influence, and therefore should be reported? b. “witch milk” c. Slight vaginal bleeding d. Undescended testicles e. Linea negra
5. A woman who is a primipara at term is in active labor and is complaining of severe backache with contractions. Which of the following is not an effective comfort measure? b. Massage to the lower back between contractions c. External pressure to the sacrum during contractions d. Assistance with ambulation e. Position on side with pillows between legs.
Answer:1. b Sign of potential fetal distress. It can result from fetal hypoxia and acidosis and certain drugs that depress the central nervous system. A baseline range of 110-160 bpm is within normal limits
Answer 2. a Lightening or descent of the fetus puts added pressure on the bladder, causing frequency.
Answer 3 c. Term infants may lose 5%-10% of their birth weight
Answer 4 c. Undescended testicles is a condition unrelated to maternal hormonal influence. By 36 – 38 weeks of gestation, they should be descending through the inguinal canal and into the scrotal sac.
Answer 5 c. Ambulation would increase back discomfort by increasing fetal descent.
A.
B.
Two hip bones (right and left innominate: Sacrum, coccyx). Innominate bones are consists of the: 1. Ilium 2. Ischium 3. Pubis
1. False pelvis – upper portion above pelvis brim, supportive structure for uterus during last half of pregnancy.
2.True pelvis – below brim; pelvic inlet, midplane, pelvic outlet. Fetus passes through during birth
PELVIS Four Types: 1.Gynecoid Pelvis 2. Android Pelvis 3. Anthropoid Pelvis 4. Platypelloid Pelvis
1.Gynecoid Pelvis Inlet is round Wide This is the typical FEMALE PELVIS Most favorable for normal spontaneous delivery
2. Android Pelvis Wide HEART-SHAPED This is the typical MALE PELVIS
3. Anthropoid
Pelvis Wide Narrow This is the typical APE PELVIS
4. Platypelloid Pelvis Opposite of Anthropoid Pelvis Wide Narrow
A.
Diagonal conjugate – 12.5 cm or greater is adequate size, evaluated by examiner
C.
Conjugate vera – 11 cm is adequate size; can be measured by x-ray (not commonly performed)
C. Obstetric conjugate – measured by x –ray (not commonly performed) D. Tuber-ischial diameter – 9 -11 cm indicates adequate size; evaluated examiner.
DIAMETERS OF THE PELVIS Sagittal section Obstetric Conjugate ◦ A conjugate that CANNOT BE MEASURED CLINICALLY ◦ Distance from posterior surface of symphysis pubis up to the most prominent portion of sacral promontory
Subtract 1.5 – 2.0 cm from diagonal conjugate Therefore, Obstetric Conjugate (OC) is equal to Diagonal Conjugate (DC) minus 1.5 to 2.0 centimeters. In equation form:
◦ OC = DC – 1.5 or 2.0 cm
Diagonal Conjugate Distance from posterior surface of symphysis pubis and the inferior margin of symphysis pubis up to the most prominent area of the sacrum Only conjugate that can be measured clinically Normal value is 11.5 cm to 12.5 cm.
A. B. C.
D. E.
F. G.
Mons veneris – protects symphysis Labia majora – covers, protects labia minora Labia minora – two located within labia majora Clitoris – small erectile tissue Hymen – thin membrane at opening of vagina Urinary meatus – opening of urethra Bartholins glands – producer of alkaline secretions that enhances sperm motility, viability.
Vagina – outlet for menstrual flow, depository of semen, lower birth canal
Cervix – cone-shaped neck of the uterus that protrudes into the vagina
OVARY Ovulation is the most important function of the ovary Production of the female hormone Situated retroperitoneally
Contained in the OVARIAN FOSSA In times of abdominal new growth in the ovary – these are always detected late due to anatomical location Example: ◦ Ovarian carcinoma ◦ Ovarian malignancy Not easily palpable
UTERUS Changes occurring during pregnancy Endometrium lining during pregnancy becomes deciduas (lining of the pregnant uterus) Endometrium is the lining of the NONPREGNANT UTERUS
2.
Decidua Basalis Decidua immediately beneath the implantation of the blastocyst
2. Decidua Capsularis Decidua covering the blastocyst
3. Decidua Vera This is the remaining portion of the decidua Decidua that is not Basalis nor Capsularis
Desidua Basalis
◦ Most important among the deciduas ◦ Limits invasion of CHORIONIC VILLI into the MYOMETRIUM ◦ Placenta will not be delivered spontaneously if basalis is NOT WELL DEVELOPED ◦ This will result into a condition known as PLACENTA ACCRETA
Placenta Accreta ◦ Presence of faulty attachment of the chorionic villi of the placenta into the myometrium ◦ The main problem in Placenta Accreta is HEMORRHAGE
◦ Therefore, the decidua basalis should be well developed
FALLOPIAN TUBE Site of fertilization More specifically, the AMPULLA of the Fallopian Tube is the site of fertilization Distal Third of the Fallopian Tube Composed of the ◦ Ampulla and Fimbriae
Ampulla ◦ Has the widest diameter among the segments of the fallopian tube
Middle Third of the Fallopian Tube ◦ Composed of the ISTHMUS
Proximal Third of the Fallopian Tube ◦ Composed of the INTERSTITIAL SEGMENT or the INSTERSTITIAL PART
a.
Health history 1. menarche; onset and duration 2. menstrual problems 3. contraceptive use 4.Pregnancy history fertility problems lifestyle
B. Physical examination 1. external, internal reproductive organs 2. breast examination 3. mammography – every 1-2 years for women beginning 40 annually beginning age 50 more frequently if have risk factors for breast cancer.
C. Pap smear – first Papaniculaou smear at age 18 or earlier if sexually active; then annually until 3 consecutive normal Pap smear. D. Test for sexually transmitted disease.
1.
Follicle stimulating hormone (FSH) – secreted during the first half of cycle; stimulates development of graafian follicle; secreted by anterior pituitary gland.
2. Interstitial cell- stimulating hormone, or leuteinizing hormone (ICSH, LH) - stimulates ovulation and development of corpus luteum; secreted by pituitary gland.
3. Estrogen – assists in ovarian follicle maturation; stimulates endometrial thickening; responsible for development of secondary sex characteristics; maintains endometrium during pregnancy. secreted by ovaries and adrenal cortex during cycle and by placenta during pregnancy.
4. Progesterone – aids in endometrial thickening; facilitates secretory changes; maintains uterine lining for implantation and early pregnancy; relaxes smooth muscle. Secreted by corpus luteum and placenta.
5. Prostaglandins – substances produced by various body organs that act hormonally on the endometrium to influence the onset and continuation of labor. Used to efface the cervix before induction of labor in term pregnancies.
Puberty ◦ ◦ ◦
Begins with the first menstrual bleeding (menarche) Begins when GnRH, FSH, LH, estrogen, and progesterone levels increase Increased estrogen and progesterone promote the development of the female primary and secondary sexual characteristics
Menstrual Cycle ◦ Consists of the periodic changes occurring in the ovaries and uterus of a sexually mature, nonpregnant female that result in The production of a secondary oocyte Preparation of the uterus for implantation
◦ Days 1-5: Menstrual phase: uterus sheds all but the deepest part of the endometrium ◦ Days 6-14: Proliferation phase: endometrium rebuilds itself ◦ Days 14-28: Secretory phase: endometrium prepares for implantation of the embryo
First half of the ovarian cycle Always variable in length Follicles of ovaries are growing Uterus lining (endometrium) is proliferating Elevated Hormones
Anterior Pituitary INCREASES SECRETION OF FOLLICLE STIMULATING HORMONE ◦ Therefore, the follicle in the ovary ENLARGES ◦ As it enlarges, it becomes more mature
GRAAFIAN FOLLICLE ◦ ◦ ◦ ◦ ◦
Most mature of all follicles With cavity With ovum ready to be extruded With clear fluid rich in ESTROGEN Only one (1) follicle matures per menstrual cycle
Approximate number of growing follicles: ◦ At twenty-eight (28) weeks Age of Gestation 6,000,000
◦ At Term 1,000,000
◦ At menarche 400,000
◦ At forty (40) years of age 8,000
Thickens the uterine lining Usually eight-fold of previous
◦ From one millimeter to eight millimeter
Peak of uterine lining coincides with ovulation Peaking of Estrogen will signal Leutinizing Hormone surge or increase in blood levels of Leutinizing Hormone
LH Surge Coincides with ovulation Extrusion of ovum from the Graafian Follicle Signal for Ovulation Ovum stays in the Fallopian tube for one (1) to three (3) days Peak is twenty-four hours
Second half of the ovarian cycle Constant part ◦ Always fourteen (14) days in length
Production of Corpus Luteum ◦ Uterus / uterine lining is secretory in nature
Because of the secretion of Leutinizing Hormone ◦ ◦ ◦ ◦
Leutinizing Hormone influences follicle Cavity is left inside the follicle Stimulates change in fluid in Graafian follicle Yellowish, milky white fluid high in PROGESTERONE
Progesterone Maintains uterine lining Organizes uterine lining ◦ If only estrogen is present, the uterine lining would continue to thicken and thicken and thicken
PRO-VERA ◦ Progesterone ◦ For dysfunctional uterine bleeding ◦ For organization of the uterus
Anticipates possible fertilization If there is pregnancy, to MAINTAIN PREGNANCY
If ovum degenerates, ◦ LH and Progesterone no longer needed ◦ Therefore, there is menstruation
If there is coitus and fertilization Corpus Luteum must persist up to twelve (12) weeks of gestation After twelve (12) weeks, it degenerates and the placenta produces hormones
Approximate menstrual cycle NORMAL is 28 days 28 + or – 7 days or 21 – 35 days is also NORMAL If the menstrual period is short (i.e. 21 days), a person can menstruate twice in a month – this is still NORMAL
If a person’s menstrual cycle is 28 days, 14 days for the proliferative or follicular phase and 14 days for the secretory or luteal phase, then OVULATION IS ON THE 14TH DAY If a person’s menstrual cycle is 35 days, the OVULATION IS ON THE 21ST DAY
Given the following: Last Menstrual Period (LMP) is January 1, 2005 Menstrual Cycle is 35 days
January 2005 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 February 2005 xx xx xx 01 02 03 04 05 06 07 08 09 10 11
The LAST MENSTRUAL PERIOD or LMP is the FIRST DAY OF THE PERIOD ◦ Therefore, counting of the MENSTRUAL CYCLE, starts from this same date ◦ Thus, February 4, 2005 Is the 35th day Is the expected start of the next cycle
Is the LMP of the next cycle
Thus, February 3, 2005
Is the 34th day Is the end of the cycle that started on January 1, 2005 This is WHERE YOU START COUNTING BACK FOURTEEN DAYS TO GET THE DAY OF OVULATION
Therefore, count fourteen (14) days, starting February 3 going backward
Thus, the expected OVULATION DAY is February 21, 2005
If the cycle is irregular, do not do this procedure If the Menstrual Cycle is not given, it is UNDERSTOOD THAT IT IS 28 DAYS
CONSTANT OF 11 AND 18 Another way of getting the ovulation period if the cycle is variable is by the use of the constant of 11 and 18
Example: ◦ Menstrual Cycle is 22 – 35 days ◦ Monitor the menstrual cycle in one year’s time ◦ Subtract higher number (18) from shortest cycle 22 – 18 = 4
◦ Subtract lower number (11) from the longest cycle ◦ 35 – 11 = 24
Therefore, from the 4th to the 24th day of the cycle, there is NO COITUS ◦ There is 80% failure in the rhythm method
If menstrual cycle is 28 – 35 days ◦ 28 – 18 = 10 ◦ 35 – 11 = 24
Therefore, from the 10th to the 24th day of the cycle, there is NO COITUS
Egg –approximately 24 hours after ovulation. Sperm – approximately 72 hours after ejaculation into female reproductive tract. Implantation (nidation) – occurs within 7 -9 days of conception, or about day 21 – 23 of a 28 day menstrual cycle.
Conception (fertilization) – usually occurs within 12 -24 hours after ovulation, within fallopian tube. Ovum – period of conception until primary villi have appeared; about 12 – 14 days
EMBRYO Product of Fertilization Approximately 3 cm; 54 – 56 days Pre-embryonic Period ◦ Zero (0) to two (2) to three (3) weeks
Embryonic Period ◦ Two (2) to three (3) weeks to eight (8) to ten (10) weeks
FETUS Period from end of embryo stage until birth. Eight (8) to ten (10) weeks up to time of delivery
VIABILITY A fetus can be delivered Capable of living outside utero Period of Viability is TWENTY (20) WEEKS AND ABOVE
GRAVIDA Number of pregnancies REGARDLESS OF THE OUTCOME PREGNANT WOMAN d. Nulligravida – never been pregnant e. Primigravida – first pregnancy f. Multigravida – a woman with a second or later pregnancy
PARITY Number of pregnancies THAT REACH THE AGE OF VIABILITY REGARDLESS OF THE OUTCOME OF PREGNANCY (should be delivered) Refers to the past pregnancies ( not number of babies) that reached viability (20-22 wk whether or not born alive)
NULLIPAROUS A woman who has not carried a pregnancy to viability (may have had one or more abortions) Pregnancy did not reach age of viability ◦Therefore, PRIMIGRAVID, NULLIPAROUS
Primipara – a woman who has carried one pregnancy to viability. Multipara – a woman who had two or more pregnancies that reached viability. Grandmultipara – woman who has had six or more viable pregnancies.
GTPAL G - describes number of gravida (pregnancy) T is for Term (37 weeks and above) P is for Pre-term (20 to 36 weeks) A is for Abortion (any terminated pregnancy less than 20 weeks; 19 wks and below) L is for Living children
Presumptive ◦ More of a symptom rather than a sign
Possible Positive
PRESUMPTIVE SYMPTOMS – subjective experiences 2. Amenorrhea more than 10 days past missed menstrual period. Breast tenderness, enlargement Nausea and vomiting Quickening (wk 16-18) Urinary frequency Fatigue Constipation (50% of women)
Presumptive signs Striae gravidarum linea negra, chloasma (after 6 week) Increased basal body temperature
Probable signs - examiner’s objective findings positive pregnancy test Enlargement of abdomen/uterus Reproductive organ changes (after six week)
3. Changes in Urination Urinary frequency ◦ Present in First and Third Trimester ◦ No Urgency
Second Trimester ◦ This disappears ◦ Uterus starting to enlarge in First Trimester ◦ Uterus becomes abdominal organ in the second trimester ◦ This releases pressure on the bladder
Third Trimester Uterus enlarges and presses again against the bladder in the Third Trimester
4. Nausea and Vomiting Human Chorionic Gonadotropin ◦ Primigravida Mostly manifests this
Peaks at FIRST TRIMESTER ◦ At two (2) to three (3) months of pregnancy ◦ At eight (8) to twelve (12) weeks of pregnancy
Provide: Dry unsalted crackers Ice chips Small, frequent feedings Six (6) times a day This is the best among all the options
Split food into two halves and give meals after every two (2) hours Less fatty foods in diet Do not lie supine after eating Encourage ambulation
Progesterone decreases gastric emptying! If nausea and vomiting is severe consider ◦ Hydration ◦ Vomiting ◦ Hypokalemia, presenting as generalized weakness ◦ Electrolyte Balance
Therefore, client needs to be admitted
5. Fatigue Diaphragm does not descend upon inspiration
6. Skin Changes Brought about by hormonal changes ESTROGEN ◦ Cloasma Mask of pregnancy Visible at the cheek
◦ Melasma Darkening of the neck
◦ Linea Negra From the symphysis pubis to the umbilicus
◦ Striae Gravidarum Silvery in color Due to distention of the collagen of the abdomen as the uterus enlarges
PROBABLE SIGNS More of the signs 1. Abdominal Enlargement Symmetrical and globular High risk Less than eighteen (18) weeks
See different Landmarks:If uterus is at the level of the symphysis pubis ◦ Age of Gestation = 12 weeks
If uterus is midway between umbilicus and symphysis pubis Age of Gestation = 16 weeks
If uterus is at the level of the umbilicus ◦ Age of Gestation = 20 weeks
Then, increase of one centimeter (1 cm) in FUNDIC HEIGHT = Additional Four (4) weeks in Age of Gestation ◦ ◦ ◦ ◦
1 2 3 4
cm cm cm cm
above above above above
the the the the
umbilicus umbilicus umbilicus umbilicus
= = = =
24 28 32 36
wks wks wks wks
At the LEVEL OF THE XIPHOID PROCESS, Age of Gestation is 36 weeks If one centimeter (1cm) below the xiphoid process, Age of Gestation is 40 weeks due to LIGHTENING (presenting part enters the true pelvis) or DESCENT
Lightening or Descent occurs ◦ In Primigravida Two weeks earlier
◦ In Multigravida Occurs during the time of labor
2. BALLOTTEMENT When you tap the uterus, there is a sensation that something is sinking and floating Sinking and floating of fetus in the uterus Appreciated at sixteen (16) to twentyfour (24) weeks only After twenty-four weeks (> 24 weeks), NO BALLOTEMENT OCCURS
This is because the size of the baby is greater in respect to the amniotic fluid
3. BRAXTON HICKS False labor Palpable uterine contraction Starts at approximately twenty-eight (28) weeks and above This is okay unless it does not give progressive cervical dilatation
4. CHADWICK’S SIGN Bluish-purple coloration of the vagina due to increase in vagina’s vascularity Vagina becomes swollen due to estrogen and progesterone purple hue in vulvar/ vaginal area.
Increase in acidity of vaginal pH due to lactobacillus acidophilus Lactobacillus acidophilus protects the vagina from ascending infection but favors increased growth of candidiasis Candidiasis
◦ This problem increases in pregnancy
5. GOODEL’S SIGN Softening of the cervix to ready cervix for dilatation and effacement Increased vascularity (red and bluish cervix) Hyperplasia and hypertrophy of cervical glands (uterus hypertrophy only) – cervical softening.
Increased cervical glands Increased cervical secretions Leukorrhea or white secretions Cervical secretions coagulation or clumping resulting into MUCOUS PLUG or OPERCULUM Operculum
◦ Protects the baby and the placenta from ascending infection
Hegar’s sign – softening of the lower uterine segment
POSITIVE PREGNANCY TEST HCG levels determine this Ten (10) days after missed period, this can be detected
Peak of level of HCG is ten (10) weeks Age of Gestation or 2½ months Then it goes down Therefore, yield of positivity of pregnancy tests to go down after ten (10) weeks
1. FETAL HEART TONE 1.1) Ultrasound ◦ Cardiac pulsation as early as six (6) to eight (8) weeks 1.2) Doppler Fetal heart tone at ten (10) to twelve (12) weeks
1.3) Fetoscope / Stethoscope Fetal heart tone at eighteen (18) to twenty (20) weeks
1.4) External Electronic Fetal Monitor Fetal heart tone at twenty-four (24) weeks Age of Gestation
2. QUICKENING Quickening felt by the examiner is a positive sign of pregnancy Quickening felt by the mother is a presumptive sign In Primigravida
◦ This occurs later than twenty (20) weeks
In Multigravida
◦ This occurs earlier than sixteen (16) weeks
3. X-RAY / FETAL SKELETON APPRECIATED X-ray on pregnant mother is okay as long as there is ABDOMINAL SHIELD This is done on the SECOND (2nd) or THIRD (3rd) TRIMESTER but NEVER DURING THE FIRST (1st) TRIMESTER
4. PULSATION OF HEART OF BABY THROUGH ULTRASOUND MATERNAL PHYSIOLOGY Pregnancy Duration ◦ 280 days
- 40 weeks - 10 lunar month s
1. WEIGHT GAIN Twenty-five (25) to thirty-five (35) pounds First Trimester ◦ Four pounds (4 lbs.) ◦ Only organogenesis occurs ◦ No muscle growth
Second Trimester ◦ Eleven pounds (11 lbs.)
Third Trimester ◦ Eleven pounds (11 lbs.)
One (1) to two (2) pounds per week is the allowable weight gain during the FIRST (1st) and SECOND (2nd) TRIMESTER
On the LATE THIRD TRIMESTER (36 weeks and above), allowable weight gain is one pound per week (1 lb. / week)
2. WATER METABOLISM Four (4) to six (6) liters of water are retained during pregnancy Thirty to fifty percent (30% to 50%) of this amount can enter into the circulation (approximately 2 – 3 liters) to intravascular space
This INCREASES the CARDIAC OUTPUT Therefore, pregnant people with HEART CONDITIONS are AT-RISK!!!
Increased Progesterone ◦ Relaxes smooth muscles ◦ Decreases peripheral resistance
Therefore, Blood Pressure should REMAIN THE SAME or should DECREASE DURING PREGNANCY
Sodium ◦ Dilutional Hyponatremia occurs in pregnancy due to increased water retention ◦ Therefore, DO NOT RESTRICT SALT INTAKE DURING PREGNANCY
Just maintain sodium intake of three (3) grams per day
3. PHYSIOLOGIC ANEMIA Due to increase in plasma value ◦ Dilutes circulating Red Blood Cells ◦ Therefore, take the Complete Blood Count in the initial assessment to get the blood picture of the client
Give iron supplementation ◦ Do this in the second trimester because this is the time when iron stores are depleted ◦ Best taken at night ◦ Metallic taste is ◦ Give with food
A gastric irritant ◦ ◦ ◦ ◦
Followed by orange juice Acidic environment provides greater absorption Advise that client will have black stool Client taking iron is constipated
Therefore, increase oral fluid intake and iron
4.CARBOHYDRATE METABOLISM Pancreas is enlarged ◦ Increased insulin secretion ◦ Pregnancy is a diabetogenic state ◦ A paradox!!!
If pre-pregnant mother is diabetic
◦ Two to three percent (2% to 3%) chance of having gestational diabetes ◦ Placenta COUNTERACTS INSULIN by INSULINASE ◦ Insulinase breaks insulin
Human Placental Lactogen
◦ Secreted only during pregnancy ◦ Promotes lipolysis
INSULINASE and HUMAN PLACENTAL LACTOGEN ◦ Increased sugars in blood prevents starvation of baby in case of maternal starvation
5. PROTEIN METABOLISM Increase in need of protein during pregnancy Additional ten grams (10 g) of protein per day to be added to non-pregnant diet
Placenta is made up of fatty acids FAT METABOLISM
◦ Add to diet ◦ A little increase in fat in the diet is necessary
Iron supplementation in pregnancy is DOUBLED In pre-pregnancy
◦ Fifteen grams per day (15 g / day)
In pregnancy Thirty grams per day (30 g / day)
1. HISTORY 2. PHYSICAL EXAMINATION 2.1) Take Blood Pressure Well rested mother for fifteen (15) minutes Blood Pressure Variations with Position
Sitting ◦ BP is slightly higher ◦ Highest reading of the three positions
Supine ◦ Intermediate reading
Left Lateral Lowest reading among the three positions
2.2) IPA In pregnant women, assessment would consist of: ◦ Inspection ◦ Palpation ◦ Auscultation
NO PERCUSSION
2.3) FOCUS ON ABDOMEN Inspection
◦ Look for striae ◦ Look for hernia of umbilicus
Palpate ◦ ◦ ◦ ◦
Take the fundic height Supine position with both legs flexed Use centimeter scale of tape measure Place at TIP OF SYMPHYSIS PUBIS up to the level of FUNDUS AND NOTE THE MEASUREMENT
2.4) PERFORM LEOPOLD’S MANEUVER Purpose of Leopold’s Maneuver
◦ To know where the fetal back is ◦ To get Fetal Heart Tone
Let patient void before performing Leopold’s Maneuver In the first three maneuvers, the nurse FACES THE HEAD PART OF THE MOTHER
2.4.1) LEOPOLD’S 1 Performed to know. . . What part of the baby occupies the fundus of the uterus?
FUNDAL GRIP How is Leopold’s 1 done? Use both hands Palpate the fundus of the uterus in a circular manner
Locate if the fundus has: ◦ HEAD
Round Hard Ballottable mass
◦ BREECH (buttocks) Soft Irregular With nodulations (coccyx, bilateral aspect of buttocks)
Question: What Leopold’s maneuver will you use to know the presentation of the fetus? Answer: Leopold’s 3
In Leopold’s 1, we know what is the LIE of the baby FETAL LIE
◦ Is the relationship of the long axis of the mother to the long axis of the baby
Types of Fetal Lie Transverse Lie
◦ Baby is perpendicular to the long axis of the mother ◦ HORIZONTAL ORIENTATION
Longitudinal Lie ◦ Baby is parallel to the long axis of the mother
VERTICAL ORIENTATION
If baby is in a TRANSVERSE LIE, LEOPOLD’S 1 is NEGATIVE
LEOPOLD’S 2 Performed to know. . . Where is the FETAL BACK? Where is the UMBILICAL GRIP?
How is Leopold’s 2 done? Use both hands Palpate the side of the mother
If at longitudinal lie ◦ Fetal Back Bony, convex mass represents the vertebral column
◦ Fetal Small Parts Small, irregular mass represents the knuckles and knees
If at transverse lie ◦ Head or Buttocks will be located
If you locate the back, place stethoscope at the back where FETAL HEART TONE is MOST AUDIBLE
LEOPOLD’S 3 Performed to know. . . What part of the baby lies just above the pelvic inlet PAWLIK’S GRIP
How is Leopold’s 3 done? Use dominant hand Grasp area just above the symphysis pubis If you grasp the head
◦ Round ◦ Hard ◦ Ballotable mass
If breech ◦ Soft ◦ Irregular ◦ With nodulations (coccyx, bilateral aspect of buttocks)
You will ALSO KNOW if PRESENTING PART IS ENGAGED or NOT ENGAGED
If head is engaged, ◦ If head is already descended, you will not feel the head ◦ If head has not descended fully to the pelvic inlet (partial descent), you can feel for the shoulders of the baby ◦ If head is unengaged, you can grasp head and you can move it sideways
FETAL PRESENTATION is best determined by LEOPOLD’S 3 because IT IS DIRECT. LEOPOLD’S 1 is INDIRECT
LEOPOLD’S 4 Performed to know. . . What is the ATTITUDE of the fetus? FETAL ATTITUDE
◦ This is the degree of flexion of the baby in utero
Types of Fetal Attitude Flexed Suboccipitobregmatic
diameter is presented Approximately nine centimeters (9cm) Note: Bregma is anterior
Extended It cannot pass through suboccipitomental diameter, which is greater than thirteen centimeters (>13 cm) Thus, there will be LONG LABOR Cervical Dilatation will not proceed Therefore, CAESARIAN SECTION is PERFORMED
You also note the DEGREE OF FLEXION or ATTITUDE of the fetus or PELVIC GRIP
How is Leopold’s 4 done? Face the foot part of the mother Use both hands Palpate the side of the mother going to the midline of the symphysis pubis
If in extension attitude ◦ There is RESISTANCE ◦ This occurs when you hit NAPE AREA
Note: Your hand will feel a depression and then will feel the ascending curve going towards the head
If in complete flexion ◦ Cephalic prominence is on the same side as fetal small parts (feet and knees)
If in complete extension ◦ Cephalic prominence is on same side of fetal back
Two (2) things to know from LEOPOLD’S 4 ◦ Fetal Attitude or the degree of flexion ◦ Cephalic Prominence
Prepare mother psychologically during prenatal check-up
FIRST TRIMESTER Mother should accept that she is pregnant (though ambivalence may be present) Concern of the mother towards herself is greater than her concern towards the baby
SECOND TRIMESTER Acceptance of baby is the main task Concern towards the self is EQUAL to concern for the baby
THIRD TRIMESTER Acceptance of parenthood Concern for the self is LESS than concern for the baby
a. b. c.
Once monthly – until week 28. Every 2 week – week 28 – 36 Weekly – week 36 until labor
THEORIES OF PARTURITION FETAL SIGNAL The baby feels that it is already capable of living outside utero
Example: ◦ Fetus with Normal Spontaneous Delivery go into Post Maturity, delivered 42 – 43 weeks ◦ This is because fetus feels something is still lacking in his or her body
OXYTOCIN THEORY OF PARTURITION Receptors for oxytocin in the uterus increases as term approaches
Level of progesterone assayed in pre-term and term pregnancy Pre-term
◦ Progesterone level is still high
Approaching Term ◦ Level of progesterone DECREASES causing CONTRACTION OF THE UTERUS
Premature ◦ Low levels of prostaglandin
Term / Post Term ◦ High levels of prostaglandin
Important Concepts! Prostaglandin causes uterine contraction
COITUS is CONTRAINDICATED if you have a history of PREMATURITY since SEMEN CONTAINS PROSTAGLANDIN
1. PELVIC DIMENSION 2. FETAL DIMENSION
A) Fetal Size Correlation of size of baby to pelvic size Cephalopelvic Disproportion (CPD) Head of baby is INCONGRUENT with the pelvis Head Size is greater than the Pelvis
B) Fetal Posture or Attitude If in complete extension, labor will not progress C) Fetal Lie If fetus is in TRANSVERSE LIE, DILATATION will NOT PROGRESS
D) Fetal Presentation If breech and PRIMIGRAVIDA NO NORMAL SPONTANEOUS DELIVERY If breech and MULTIGRAVIDA POSSIBLE NORMAL SPONTANEOUS DELIVERY
E) Fetal Position Relationship of the four (4) quadrants of the pelvis of the mother to the presenting part
F) Fetal Station Relationship of presenting part to ISCHIAL SPINES If head of baby descends in the pelvis, the head of the baby is AT THE LEVEL OF THE ISCHIAL SPINE
THEREFORE, STATION IS ZERO 1 cm above ischial spine = -1 2 cm above ischial spine = -2 3 cm above ischial spine = -3 4 cm above ischial spine = -4
At station of –4, head is still floating The presenting part is in the FALSE PELVIS The LINEA TERMINALIS is an imaginary dividing line that
divides the FALSE and TRUE PELVIS Above the linea terminalis is the FALSE PELVIS Below the linea terminalis is the TRUE PELVIS
If engaged, head is not necessarily at STATION ZERO From STATION –3, the head is ALREADY ENGAGED!!! Below the Ischial spine, the reckoning is POSITIVE
1 2 3 4
cm cm cm cm
below below below below
ischial ischial ischial ischial
spine spine spine spine
= = = =
+1 +2 +3 +4
At station +4, head is already CROWNING or SHOWING AT THE INTROITUS
3. FETAL HEAD Fontanelles ◦ Give rise to molding
Molding ◦ Overlapping of sutures to accommodate head through the pelvis
Anterior Fontanelle ◦ Diamond shaped ◦ Closes at nine (9) to eighteen (18) months
Posterior Fontanelle Triangular shaped Closes at two (2) to three (3) months
TRUE LABOR Starts at lumbar area or the back Regular interval Progressive cervical dilatation and effacement Intensity is increasing Ambulation intensifies uterine contraction in true labor Sedation has no effect
FALSE LABOR Confined to hypogastric area or lower abdomen Irregular interval No cervical dilatation and effacement No change or decreasing intensity Ambulation stops uterus contraction Sedation stops false labor
UTERINE CONTRACTION Timing is done by the nurse Use balls of the finger and palpate fundus of the uterus In the United States, the mother is hooked to an external monitor
Example: Contraction starts 7:00 AM Lasts 60 seconds 7:01 AM Second contraction 7:04 AM Duration is 60 secs 7:05 AM Third contraction 7:08 AM
Interval ◦ From end of first contraction to the beginning of the next contraction ◦ 7:01 AM to 7:04 AM ◦ Therefore, three (3) minutes
Frequency ◦ Beginning of one contraction to beginning of next contraction ◦ 7:00 AM to 7:04 ◦ Therefore, four (4) minutes
Duration ◦ From the beginning to end of one contraction ◦ 7:00 AM to 7:01 AM ◦ Therefore, one (1) minute
Intensity ◦ This is a subjective term ◦ May be classified as: Mild Contraction Examining finger can be indented but uterus is still contracting
Moderate Contraction Examining finger can be indented but uterine contraction is more than in mild
◦ Strong Contraction You cannot indent examining finger because the abdomen is board-like in consistency (hard)
1. LIGHTENING In Primigravida
◦ Two (2) weeks prior to labor
In Multigravida ◦ At time of labor
2. BRAXTON HICKS CONTRACTIONS Starting at twenty-eight (28) weeks Age of Gestation This is normal, provided there is NO CERVICAL DILATATION
3. INCREASE IN VAGINAL SECRETION An attempt to remove mucous plug
4. SOFTENING OF THE CERVIX HEGAR’S SIGN For effacement and dilatation
5. BLOODY SHOW Secondary to descent of presenting part Capillaries in the floor of pelvis are ruptured by presenting part or pressing on the pelvis
STAGE 1 TRUE UTERINE CONTRACTION TO FULL CERVICAL DILATATION (10 cm) For Primigravida (in normal circumstances) First Stage lasts for eight (8) to twelve (12) hours
For Multigravida (in normal circumstances) First Stage lasts for six (6) to eight (8) hours In Precipitate Labor Entire labor is through within three (3) hours
PHASE 1 LATENT PHASE OF FIRST STAGE OF LABOR Cervical Dilatation
◦ Zero centimeters (0 cm) to three (3 cm)
Uterine Contraction ◦ Duration Twenty (20) to Forty (40) seconds
◦ Interval Five (5) to ten (10) minutes
◦ Intensity Mild Intensity
PHASE 2 ACTIVE PHASE OF FIRST STAGE OF LABOR Cervical Dilatation
◦ Four centimeters (4 cm) to Seven (7 cm)
Uterine Contraction ◦ Duration Thirty (30) to Fifty (50) seconds
◦ Interval Two (2) to Five (5) minutes
◦ Intensity Moderate Intensity
PHASE 3 TRANSITIONAL PHASE OF FIRST STAGE OF LABOR Cervical Dilatation
◦ Eight centimeters (8 cm) to ten (10 cm)
Uterine Contraction ◦ Duration Up to sixty (60) seconds
◦ Interval Two (2) to three (3) minutes
◦ Intensity Strong Intensity
FROM FULL CERVICAL DILATATION UP TO DELIVERY OF THE FETUS In Primigravida
◦ One (1) to four (4) hours long
In Multigravida ◦ Twenty (20) to forty-five (45) minutes only
In a client in labor – A primigravida client, when will you transfer the client from the labor room to the delivery room? a.if cervix is fully dilated b.if in active labor c.if in transitional labor (8 – 10 cm) d. Anytime
Answer: ◦ Letter A
◦ If patient is Multigravida
Best time to transfer patient from the labor room to the delivery room is the TRANSITIONAL PHASE Transfer the client even while she is at eight centimeters (8 cm) dilatation
MECHANISMS OF LABOR IN VERTEX OR HEAD PRESENTATION
POSITION OF FETUS Relationship of the four (4) quadrants of mother to the presenting part Mother is facing you Symphysis pubis is ANTERIOR Vertebra of mother is POSTERIOR
Engagement Descent Flexion Internal Rotation Extension External Rotation Expulsion
Common Board Questions Give the correct sequence of the mechanisms of labor
DELIVERY OF BABY TO DELIVERY OF PLACENTA Lasts for five (5) to ten (10) minutes Maximum waiting time is thirty (30) minutes Beyond thirty (30) minutes is ALREADY ABNORMAL
1. Calkins’s Sign ◦ Uterus becomes firm and globular
2. Lengthening of the Cord
3. Sudden Gush of Blood 4. Rising of the Uterus into the Abdomen ◦ Up to the level of the umbilicus or one centimeter (1 cm) after umbilicus after the delivery of the placenta
Two (2) Types of Placental Expulsion Shultz Duncan
Shiny Cotyledon is not seen Total membrane covers this
Placental separation starts at fetal side of the placenta ◦ This is the membrane
Central separation is the start Less chances of bleeding
Nursing Responsibility for the Assessment of the Placenta ◦ Expose all cotyledons If one is missing, IT REMAINS INSIDE Look for the PUNCHED-OUT AREA
◦ Measure the placental diameter ◦ Weigh the placenta Remove the clamp Normal placental weight Less than 500 grams If greater than 500 grams, there is PLACENTO-MEGALY related to congenital anomaly
◦ Measure umbilical cord Measure portion of the cord remaining with the placenta Measure portion of the cord remaining with the baby
If this is less than fifty centimeters (<50 cm), there may be SHORT CORD SYNDROME related to ABRUPTIO PLACENTA
◦ Expect Blood Vessels
Artery Small round lumen Vein Bigger lumen More collapsed
◦ Two (2) arteries and one (1) vein ◦ Mnemonic is AVA ◦ If there is only one (1) artery and one (1) vein, there is a congenital problem – A GUT PROBLEM – Genitourinary Tract Anomalies
Placental separation starts at SIDE / PERIPHERY – on the lower end of the placenta Placenta slides down to the introitus Maternal side presents (attached to myometrium) Cotyledons are easily visible Associated with more bleeding and hemorrhage
Normal Range of Number of Cotyledons ◦ Sixteen to twenty (16 – 20)
When is the best time to clamp the cord? Best time to clamp the cord is when THE CORD STOPS PULSATING
When is the best time to cut the cord? ◦ Best time to cut the cord is when THE CORD STOPS PULSATING Pulsation means blood still flows
These drugs cause contraction of the uterus 1. ERGOTRATES Includes METHERGINE I.V. or I.M. Best given immediately after delivery of placenta Massive contraction of the uterus traps placenta inside
Therefore, do not give before placental expulsion
2. OXYTOCIN Given prior to expulsion of placenta to add to contraction Given at minimal amounts Normally at a rate of eleven to twelve drops per minute (11-12 gtts / min)
After delivery of placenta, give oxytocin at GREATER AMOUNTS
Important Nursing Considerations! Methergine ◦ Prior to administration, check blood pressure ◦ If BP is greater than 140/90, WITHHOLD METHERGINE
Oxytocin ◦ Never given in direct bolus ◦ Never push
◦ Causes UTERINE HYPERTONUS Tetanic contractions of the uterus or UTERINE ATONY
◦ Always dripped Ten (10) units with one (1) liter
Duration and Interval of Contraction in Uterine Atony / Hypertonus
◦ Duration of Contraction Greater than seventy seconds (>70 secs) In Transitional Phase of First Stage of Labor, duration of contraction is about sixty (60) seconds
◦ Interval Less than two (2) minutes This means that rest period is decreased
Maximum interval must be maintained at two (2) to three (3) minutes
Therefore, STOP INFUSION OF OXYTOCIN AS SOON AS POSSIBLE
DO PROCEDURES IN LATE DECELERATION
Oxytocin ◦ A potent vasoconstrictor ◦ Side effect Initially is HYPERTENSION
◦ If given in bolus Hypertension will be REVERSED TO HYPOTENSION
Therefore, DO NOT GIVE OXYTOCIN IN BOLUS
Also causes WATER INTOXICATION
◦ Therefore, assess lungs of client ◦ Crackles will be present due to pulmonary edema due to water retention by oxytocin
Bleeding or Hemorrhage Uterus must be at level of umbilicus or about one centimeter (1 cm) above
If it is three centimeters (3 cm) above the umbilicus, UTERUS IS NOT CONTRACTED ◦ There would be BLEEDING
First thing to do: ◦ Massage the uterus to attempt contraction ◦ Increase the rate of oxytocin drip Nurse does this
Rate is increased from ten drops per minute (10 gtt/min) to twelve to fifteen drops per minute (12 – 15 gtt/min) ◦ Place icepack over the abdomen Remove compress every ten minutes and replace This prevents necrosis and blackening of the tissues
Inspect Perineum ◦ How to measure amount of bleeding? ◦ Utilize the PADS Count and Weigh Guide: One gram is equivalent to one milliliter (1 g = 1 ml)
◦ Qualitative Approach Mild Bleeding One (1) pad saturated in one (1) hour
Moderate Bleeding One (1) pad saturated in thirty (30) minutes
Heavy Bleeding One (1) pad saturated in fifteen (15) minutes Heavy Bleeding Perineal pads saturated at one (1) hour and if blood clots are present
◦ Palpate Abdomen Uterus contracted Perineum has bleeding
Bleeding from episiotomy (done if there is crowning or +4 station) Laceration not appraised Bleeding from cervical laceration Most common cause of bleeding Vaginal wall bleeding
DO NOT ENCOURAGE PUSHING IF CERVIX IS NOT FULLY DILATED
Question When is the best time to ask client to push? Answer
◦ Second Stage of Labor
◦ Main purpose of pushing To shorten the Second Stage of Labor Ask client to PANT-BREATHE if there is an urge to push This prevents VALSALVA MANEUVER
Remember, FIRST STAGE PUSHING IS NOT ADVISABLE
In the Third Stage of Labor, the NURSING RESPONSIBILITY is to PROVIDE MEASURES TO PREVENT HEMORRHAGE
Other Causes of Bleeding Bladder Distention
◦ Therefore, MOTHER MUST VOID AFTER GIVING BIRTH ◦ Offer bedpan every hour or accompany the mother to the bathroom (patient has HYPOTENSION)
First twelve (12) hours post partum It is NORMAL for mother to go into DIURESIS Absorbed water must be eliminated
◦ After twelve (12) hours, there is difficulty in voiding due to FATIGUE BLADDER because of CONSTANT PRESSURE EXERTED BY CONTRACTING UTERUS This results to a DISTENDED BLADDER Therefore, UTERUS CANNOT CONTRACT EFFECTIVELY
This causes UTERINE ATONY (Uterus is deflected either to the LEFT or to the RIGHT) Therefore, assure voiding so uterus stays at center
Place warm water in container ◦ Do not place warm water in abdomen or at the hypogastric area ◦ This will cause bleeding
Nursing Responsibility ◦ Do alternate pouring of warm and cold water over the perineum to promote uterine contraction
FIRST ONE (1) TO TWO (2) HOURS AFTER DELIVERY OF THE PLACENTA Crucial Problem or Main Problem at this stage ◦ BLEEDING
All the retained water retained previously will be reabsorbed into the circulation ◦ Increase in Cardiac Output ◦ Increase in Oxygen Consumption
Therefore, it is the most detrimental or difficult stage of labor in GRAVIDOCARDIAC PATIENTS!!!
ABORTION Two (2) types of Abortion Spontaneous Abortion Induced Abortion
SPONTANEOUS ABORTION Spontaneous miscarriage oocurs in 15 to 30% of all pregnancies. Early miscarriage occurs before 16 weeks; late if it occurs 16 to 24 weeks Most common cause of spontaneous abortion is teratogenic factor and Chromosomal in nature Embryo is defective Immunologic, Implantation, Progesterone is too low, Infection, Ingestion of drugs.
Assessment: Vaginal spotting. Woman’s action is important. Therapeutic management: TYPES OF SPONTANEOUS ABORTION Threatened Abortion Incomplete Abortion Inevitable / Imminent Abortion Complete Abortion Missed Abortion
Threatened – mild bleeding, spotting, cramping; cervix closed. Inevitable – moderate bleeding, painful cramping cervix dilated Imminent – profuse bleeding, severe cramping , urge to bear down Incomplete – fetal parts or fetus expelled; placenta and membranes retained.
Complete – all products of conception expelled; minimal vaginal bleeding Habitual/recurrent – history of spontaneous loss of three or more successive pregnancies. Missed – fetal death with no spontaneous expulsion within 4 weeks. Elective abortion – (intentionally introduced loss of pregnancy
Threatened abortion: Blood is drawn to monitor human chorionic gonadotropin hormone Sonogram is done to assessed viability of fetus. Avoiding strenuous activity for 24 to 48 hours is the key intervention. Imminent(Inevitable abortion). For dilation and evacuation
Complete Abortion entire product of conception are expelled spontaneously without any assistance. Incomplete Abortion Danger of maternal hemorrhage. Dilation and curettage should be done. Missed Abortion Early pregnancy failure Died 4 to 6 weeks before the onset of miscarriage symptoms Over 14 weeks may perform induced labor Disseminated intravascular coagulation.
Recurrent Abortion Occurs in 1% of pregnant women. Possible causes: 4. Defective spermatozoa or ova 5. Endocrine factors 6. Deviations of uterus. 7. Infection 8. Autoimmune disorder
6. 7. 8. 9.
Danger in MISSED ABORTION is SEPSIS Particularly if products of conception stay for more than two (2) weeks, there is INFECTION and DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC) DIC may also occur from induced abortion (abortion with catheterization) Offending organism is gram negative anaerobe Other complications: Hemorrhage Septic abortion Isoimmunization Anxiety
◦ Gram negative organism secretes ENDOTOXINS Causes destruction of capillaries Results in turbulence in blood flow Blood will seep out through the capillaries Platelets will go to site of destruction Platelets consumed
Therefore, also called CONSUMPTIVE COAGULOPATHY
Disseminated Intravascular Coagulopathy patients: ◦ Die of continuous bleeding ◦ Have patches of hematoma ◦ Have hypotension leading to SEPTIC SHOCK due to dilatation caused by ENDOTOXIN ◦ Fibrinogen level are too low. ◦ Associated with premure separation of placenta, pregnancy induced hypertension, placental retention, septic abortion, retention of dead fetus.
In septic shock, the extremities are warm ◦ All other forms of shock have COLD EXTREMITIES
ECTOPIC PREGNANCY Implantation outside the uterus Mostly tubal in nature (95%): 80% Ampulla, 12% isthmus, 8% fimbria. 2nd most common cause of bleeding in early pregnancy Can be abdominal pregnancy Can be ovarian pregnancy Abdominal and ovarian pregnancy account for five percent (5%)
Most common predisposing factor ◦ PELVIC INFLAMMATORY DISEASE or PID ◦ Others chronic salpingitis, congenital malformation, scars, uterine tumor.
Other factors: ◦ Previous Surgery May lead to adhesion Peritoneum may adhere to fallopian tube
◦ Presence of Intrauterine Device ◦ History of previous ectopic pregnancy (on opposite side)
TRIAD OF MANIFESTATIONS Amenorrhea Vaginal bleeding or SPOTTING UNILATERAL ABDOMINAL PAIN or TENDERNESS
◦ Usually lower abdomen
CLINICAL MANIFESTATIONS OF ECTOPIC PREGNANCY Severe, sharp knife-like abdominal pain
◦ Unilateral pain
Abdominal rigidity ◦ Bleeding inside ◦ Hemoperitoneum ◦ Peritonitis
Positive (+) for Cullen’s Sign ◦ Ecchymosis around the umbilicus due to hemoperitoneum ◦ Sign of peritoneal irritation
Decreased Blood Pressure ◦ About 80 / 50
Excruciating Pain when the cervix is moved
In ectopic pregnancy, blood goes to the peritoneum ◦ Blood ruptures and pools at CUL DE SAC or the POUCH OF DOUGLAS or URETERORECTAL POUCH
When internal examination is done and cul de sac is palpated, WRIGGLING SENSATION arises
DIAGNOSIS FOR ECTOPIC PREGNANCY CULDOCENTESIS You get something from the cul de sac
How is Culdocentesis done? Consent Lithotomy position Prepare Perineum Speculum introduced
◦ Held in place
To visualize the cervix
◦ No anesthetic is given
Spinal needle directed towards posterior portion of the cervix Aspirate
If blood is present in the cul de sac, it is a RUPTURED ECTOPIC PREGNANCY If there is blood. . .
◦ It is tested to make sure it comes from ectopic pregnancy and NOT MATERNAL BLOOD ◦ Blood is placed in a test tube / disk and observed for clotting
If NON-CLOTTING OR LAKED BLOOD ◦ It comes from ectopic pregnancy
If BLOOD CLOTS It is maternal blood
MANAGEMENT FOR ECTOPIC PREGNANCY MEDICAL MANAGEMENT METHOTREXATE A sclerosing agent
◦ To shrink and absorb products of conception and eventual absorption to the circulation
If ectopic pregnancy is less than three centimeters (3 cm) ◦ Given I.M. to the mother
SURGICAL MANAGEMENT Salphingostomy Limited to UNRUPTURED (less than three centimeter (3 cm)) “binubutas, tinatanggal” Left to heal
Salphingotomy Limited to UNRUPTURED “binubutas, tinatanggal” Sutured Salphingectomy For a ruptured ectopic pregnancy
Conditions Associated with secondTrimester bleeding Hydatidiform mole (H-MOLE) Predisposing Factors: ◦ Low socio-economic status ◦ Low protein intake ◦ Age Less than eighteen (<18) Greater than thirty-five (>35)
PROBLEM IN H-MOLE There is an abnormal degeneration of the chorionic villi Vesicle-like structure is formed instead of placenta May be antecedent to choriocarcinoma
Genetic base of complete mole (sperm enters empty egg and its chromosomes replicates; 23 pairs of chromosomes are all paternal). More common in women over 45 years of age and women who are Asian.
A.
B.
C.
uterus – rapid enlargement; fundal height inconsistent with gestational estimate. Brownish discharge – beginning about wk 12; may contain vesicles. Signs and symptoms of preeclampsia/eclampsia (before third trimester), increased incidence of hyperemesis gravidarum.
1.
2.
sonography, x-ray, amniography – no fetal parts present; “snowstrom” Laboratory test – for elevated human chorionic gonadotropin (HCG) levels.
NURSING RESPONSIBILITIES IN H-MOLE SUCTION CURETTAGE “Sinisipsip” “Ayaw kayudin ang uterine lining”
Purpose of Suction Curettage ◦ To prevent cancer of CHORIONIC CARCINOMA ◦ To prevent bleeding ◦ Sinuses Open Early dissemination of tissues or METASTASIS to the lungs, brain
Lungs are the MOST common site of METASTASIS IN H-MOLE
Inability of cervix to support growing weight of pregnancy; associated with repeated spontaneous second trimester abortion.
Etiology Unknown Congenital defect in cervical musculature Cervical trauma during previous birth, abortion; aggressive, deep or repeated dilation and curettage
INCOMPETENT CERVIX / CERVICAL OS Most common cause of Habitual Abortion Habitual Abortion ◦ Three (3) consecutive abortions
PREDISPOSING FACTORS IN INCOMPETENT CERVIX Developmental Factors
◦ Defective collagen formation in the cervix
Repeated Trauma to the Cervix ◦ Repeated Dilatation and Curettage
MANIFESTATIONS OF INCOMPETENT CERVIX Minimal uterine contraction Vaginal Spotting Progressive dilatation of the cervix Already evident in the FIRST TRIMESTER
MANAGEMENT OF INCOMPETENT CERVIX McDonald’s Procedure Shirodkar / Barter Procedure
MC DONALD’S PROCEDURE Purse string suture applied to cervical opening ◦ Purpose is to make the cervix tense
Done if products of conception IS LESS THAN TWELVE (12) WEEKS OLD Mother is allowed to deliver by NORMAL SPONTANEOUS DELIVERY if pregnancy persists
SHIRODKAR / BARTER PROCEDURE Cervix is closed But menstrual blood is allowed to come out Delivery is via CAESARIAN SECTION
NURSING RESPONSIBILITIES IN INCOMPETENT CERVIX Bed Rest Position of choice ◦ Modified Trendelenberg ◦ Lumbar area is elevated and feet are lowered
Coitus is temporarily restricted
Tocolytic therapy is employed if there is contraction ◦ RITODRIN, TERBUTALLINE is administered to STOP CONTRACTION
Conditions Associated with ThirdTrimester bleeding PLACENTA PREVIA Important Concept! All previa types are CAESARIAN DELIVERIES !!!
FOUR (4) TYPES OF PLACENTA PREVIA 1. Low Lying Placenta Previa; Example: Gravida 7 Predisposing Factors Multiparity, Advanced maternal age, past cesarean, uterine curettage, multiple gestation, male fetus.
◦ Tumor or mass in the uterus ◦ Previous Caesarian Section Scar is avoided by the placenta
◦ Developmental Anomaly in the Uterus Bicornuate uterus
2. Marginal Placenta Previa Lower end of Placenta is TOUCHING THE INTERNAL OS 3. Partial Placenta Previa Part of placenta is OBSCURING THE INTERNAL OS
4. Total Placenta Previa Also called Placenta Previa Totalis Placenta TOTALLY COVERS THE INTERNAL OS
◦ Definitely a Caesarian Section!
Localization of Placenta ◦ Done on the second / third trimester
PLACENTAL MIGRATION Placenta moves and may move up Can occur up to thirty-two (32) weeks
Establish that the placenta is NOT PREVIA in ALL INSTANCES OF SECOND OR THIRD TRIMESTER BLEEDING ◦ Wait for the ULTRASOUND result
DO NOT DO INTERNAL EXAMINATION!!!
DOUBLE SET-UP Client with placenta previa
◦ If Internal Examination is done ◦ A stand-by team for operation is set up Due to the advent of the Ultrasound, a Double Set-up is NO LONGER DONE!!!
ABRUPTIO PLACENTA Normal Placement EARLY SEPARATION OF THE PLACENTA PRIOR TO DELIVERY OF THE FETUS Remember that separation of placenta normally occurs on the THIRD STAGE OF LABOR Frequent cause of perinatal death
In abruptio placenta, the abnormal separation OCCURS ON THE SECOND STAGE OF LABOR
If baby has SHORT CORD SYNDROME or TRAUMA, consider ABRUPTIO PLACENTA Pregnancy Induced Hypertension
◦ A common cause of Abruptio Placenta ◦ Advanced maternal age ◦ Vasoconstriction from cocaine or cigarette use
PERIPHERAL SEPARATION Better Safer Blood goes out of introitus Tachycardia Hypotensive Increases degree of separation Increases degree of fluctuation of vital signs
CENTRAL SEPARATION More dangerous Blood does not seep off through the introitus but enters MYOMETRIUM Results to difficulty in contraction of the Myometrium Uterus remains soft and boggy ◦ Uterine Atony
Therefore, HYSTERECTOMY IS DONE Called COUVELAIRE Uterus is COPPER-COLORED or BLUISH in color due to BLOOD THAT SEEPED INTO THE MYOMETRIUM
Degree of separation: Grade 0: no symptoms of separation were apparent from the maternal or fetal signs, the diagnosis that a slight separation did occur is made after birth. Grade 1: Minimal separation, but enough to cause vaginal bleeding and changes in maternal vital sigs. No fetal distress Grade 2: Moderate separation, there is evidence of fetal distress. Grade 3: Extreme separation, without intervention maternal shock and fetal death will result.
Preterm Labor Occurs before the end of week 37 of gestation. Responsible for almost two thirds of all infant deaths in the neonatal period. Associated with dehydration, urinary tract infection, chorioamnionitis, inadequate pre-natal care. Symptoms: 6. Dull, low back pain 7. Vaginal spotting 8. Feeling of pelvic pressure 9. Menstrual like cramping 10.Increased vaginal discharge
PREMATURE RUPTURE OF MEMBRANES Membranes rupture PRIOR TO ONSET OF LABOR No contractions yet
PROBLEMS IN PREMATURE RUPTURE OF MEMBRANES 1. INFECTION Gold Standard is twenty-four (24) hours If more than twenty-four hours, there will be SEPSIS
2. CORD PROLAPSE Umbilical cord goes out Position the client to TRENDELENBERG POSITION
◦ Lower the head part ◦ NICHE’S POSITION
Do not reinsert!!! Moisten OS with NSS and cover
Push the PRESENTING PART BACK and NOT THE CORD Transport client to the OPERATING ROOM Provide oxygenation Get Fetal Heart Tone Then Caesarian Section is started Never Normal Spontaneous Delivery
MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES Pregnancy can still be prolonged if PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM)
◦ Pre-term Premature Rupture of Membranes (i.e. 35 weeks)
Problems are: ◦ Infection ◦ Cord Prolapse ◦ Prematurity
Provided ◦ There is no maternal infection ◦ There is no fetal distress ◦ Mother is not in labor
Termination of Pregnancy ◦ Caesarian Section ◦ Normal Spontaneous Delivery
PREMATURE LABOR Most common cause of neonatal morbidity and mortality
◦ Eighty five percent (85%)
Preventable ◦ How?
Modify lifestyle of the mother Resolve on-going infection Ascending infection affects fetus, uterus (goes into contraction)
Management is similar to Placenta Previa Except coitus restriction throughout
POST TERM LABOR Pregnancy extends beyond forty-two (42) weeks 1. Cephalopelvic Disproportion (CPD) This leads to babies with
◦ Long nails ◦ Wrinkled Skin
2. Oligohydramnios Amniotic fluid is less than 1,000 ml Polyhydramnios is amniotic fluid level greater than 2,000 ml Related to congenital anomaly This gives rise to babies with BANDS OR CONSTRICTIONS ON BODY
3. Inadequate blood supply to the baby due to calcification of the placenta Placenta tends to harden There are whitish specks instead of black specks
4. Meconium Staining Due to distress Meconium Aspiration Syndrome
PRECIPITATE LABOR Course of labor is ABRUPT Labor lasts for LESS THAN THREE (3) HOURS
DANGERS OF PRECIPITATE LABOR Non-institutionalized Delivery
◦ Exposes baby to sepsis
Expose mother to laceration ◦ Head of baby bumps to pelvis This results to hemorrhage
Intracerebral hemorrhage of the head of baby ◦ Baby bumps to bony pelvis
BREECH DELIVERY 1. COMPLETE BREECH Baby assumes a position similar to sitting Thighs flexed to abdomen Legs flexed to thigh 2. FRANK Thighs are flexed to abdomen Legs are extended
3. INCOMPLETE BREECH Thighs are flexed to abdomen Either leg is extended outside
◦ Single Footling
Double Footling
MAIN PROBLEM Cord Prolapse
◦ Space in cervical opening ◦ Therefore, cord goes with presenting part
Head Entrapment Shoulder Dystocia
◦ Difficulty in bringing out shoulder
Normal to see Meconium Staining ◦ Buttocks get stuck Less blood supply to the gut Stress present Therefore, there is meconium
MULTIPLE PREGNANCY Two (2) types of Multiple Pregnancy Monozygotic Dizygotic
MONOZYGOTIC One (1) ovum and one (1) sperm Fertilized by single sperm Problem in cell division
Two (2) individuals Most of the time, of the same sex One (1) placenta Two (2) umbilical cords One (1) chorion (vascular outer covering)
◦ In contact with maternal side
Two (2) amnions (avascular inner covering) ◦ In contact with the fetus
DIZYGOTIC Two (2) ova and two (2) sperms fertilizing them Identical or twin of opposite sex Two (2) placenta Two (2) umbilical cord Two (2) amnions Two (2) chorions
MONOZYGOTIC TYPE OF MULTIPLE PREGNANCY ◦ More common
Increased chance of twin to twin transfusion
◦ Donor twin and recipient twin Blood of donor twin goes to recipient twin Because they share one vascular channel
◦ Donor Twin Survives Usually thin Would normalize and be okay after blood transfusion
◦ Recipient Twin Dies Develops Congestive Heart Failure Usually stout
Dystocia – difficult labor - Due to effects of factors that affect the FETUS. (3 P’s) a. Power: forces of labor (uterine contractions, use of abdominal muscles0. 1 premature analgesia/anesthesia 2. uterine overdistension (multifetal pregnancy, fetal macrosomia). 3. uterine myomas 4. grandmultiparity
b. PASSAGEWAY: resistance of cervix, pelvic structure. 1. rigid pelvis 2. distended bladder 3. dimensions of the bony pelvis: pelvic contractures
c. PASSANGER: accommodation of the presenting part to pelvic diameters. 1. fetal malposition/malpresentation a. transverse lie b. face, brow presentation c. breech presentation d. persistent occiput posterior position e. CPD 2. fetal anomalies a. hydrocephalus b. conjoined (“Siamese”) twins. c. meningomyelocele
Maternal: 2. fatigue, exhaustion, dehydration – due to prolonged labor 3. Lowered pain threshold, loss of control- due to prolonged labor, continued uterine contractions, anxiety, fatigue, lack of sleep. 4. Intrauterine infection- due to prolonged rupture of membranes and frequent vaginal examination 5. Uterine rupture – due to obstructed labor, hyperstimulation of uterus 6. Cervical, vaginal, perineal lacerations – due to obstetric interventions
Fetal: 2. hypoxia, anoxia, demise – due to decreased oxygen concentration in cord blood. 3. Intracranial hemorrhage – due to changing intracranial pressure.
Hypertonic dysfunction Increased resting tone of uterine myometrium; diminsihed refractory period; prolonged phase; Unknown etiology Theory- ectopic initiation of incoordinate uterine contractions. a. nullipara – more than 20 hours b. multipara – more than 14 hours
Assessment: 1.Onset – early labor (latent phase) 2.Contractions: a. continuous fundal tension, incomplete relaxation b. painful c. ineffectual – no effacement or dilation Signs of fetal distress a. meconium stained b. FHR irregularies 3. Maternal vital signs 4. Emotional status
Medical management: 2. Shorting acting barbiturates – to encourage rest, relaxation. 3. Intravenous fluids – to restore/maintain hydration and fluid-electrolyte balance. 4. If CPD, cesarean birth.
Nursing management: 2. Emotional support – assist coping with fear, pain, discouragement a. encourage verbalization of anxiety, fear concern. b. explain all procedure c. reassure, keep couple informed of progress.
2. Comfort measure a. position: sidelying – to promote relaxation and placental perfusion. b. bath, back rub, linen change, clean environment c. environment: quiet, darkened room – to minimize stimuli and encourage relaxation and warmth. d. encourage voiding – to relieve bladder distension; to test urine for ketones.
Hypotonic dysfunction during labor After normal labor at onset, contractions diminish in frequency, duration and strength; lowered uterine resting tone; cervical effacement and dilation slow/cease.
Etiology Premature or excessive analgesia (epidural block/spinal block) CPD Overdistention (polyhydramnios, fetal macrosomia, multifetal pregnancy). Fetal malposition/alpresentation Maternal fear/anxiety.
Assessment: 2. Onset – may occur in latent phase, most common during active phase 3. Contractions: normal previously, demonstrate: Decreased frequency Shorter duration Diminished intensity (mild to moderate) Less uncomfortable
3. Cervical changes – slow/ cease. 4. Signs of fetal distress
Uterine rupture Stress on uterine muscle exceeds its ability to stretch. Etiology Overdistention – due to large baby, multifetal gestation Old scars – due to previous cesarean births or uterine surgery Contractions against CPD, fetal malpresentation, pathological Tetanic contraction – due to hypersensitivity to oxytocin( or overdose) during induction/augmentation of labor. Injudicious obstetrics-malaaplication of forceps (application without full effacement/dilation.
Assessment: 2. Identify predisposing factors early. 3. Complete rupture: a. pain: sudden, sharp, abdominal; followed by cessation of contractions; tender abdomen. b. signs of shock; vaginal bleeding c. fetal heart tones – absent d. presenting part – not palpable on vaginal examination.
2. Incomplete rupture a. contractions: continue, accompanied by abdominal pain and failure to dilate; may become dystonic b. signs of shock c. may demonstrate vaginal bleeding d. fetal heart tone absent/bradycardia
Amniotic Fluid Embolus Acute or cor pulmonale – due to embolus blocking vessels in pulmonary circulation; massive hemorrhage due to DIC resulting from entrance of thromboplastin-like material into bloodstream.
Etiology: Amniotic fluid (with any meconium, lanugo, or vernix) enters maternal circulation through open venous sinuses at palcental site; travels to pulmonary arterioles. Triggers cardiogenic shock and anaphylactoid reaction.
Prognosis: Poor; often fatal to the mother
Assessment: 2. May occur during labor, at time of rupture of membranes, or immediately postpartum 3. Sudden dyspnea and cyanosis 4. Chest pain 5. Hypotension, tachycardia 6. Frothy sputum 7. Signs of DIC a. purpura – local hemorrhage b. increased vaginal bleeding – massive c. rapid onset of shock
Medical management: 2. IV heparin, whole blood 3. Birth, immediately, by forceps, if possible; or cesarean birth
Fetus in Jeopardy Maternal hypoxemia, anemia, ketoacidosis, Rh isoimmunization,or decrease uteroplacental perfusion
Etiology Maternal: 1. preeclampsia/eclampsia, PIH 2. heart disease 3. diabetes 4. Rh or ABO incompatibility 5. insuffient uteroplacental/cord circulation due to: a. maternal hypotension/hypertension. b. cord compression 1. prolapsed 2. knotted c. hemorrhage; anemia
Placental Problem; 1. malformation of the placenta/cord 2. premature “ aging” of placenta 3. Placental infarcts 4. abruptio placentae 5. placenta previa
Prolapsed umbilical cord Cord descent in advance of presenting part; compression interrupts blood flow, exchange of fetal/maternal gases leads to hypoxia, anoxia, death (if unrelieved)
Etiology: b. Spontaneous or artificial rupture of membranes before presenting part is engaged. c. Excessive force of escaping fluid, as in polyhydramnios. d. Malposition – breech, compound presentation transverse lie. e. Preterm or fetus who is SGA
PREGNANCY INDUCED HYPERTENSION (P.I.H.) Unknown cause Vasospasm
SCREENING PROCEDURE FOR PREGNANCY INDUCED HYPERTENSION 1. ROLL-OVER TEST Done when mother is ◦ Twenty-eight (28) to thirty-two (32) weeks Age of Gestation
With increased cardiac output ◦ Mother is rested for fifteen (15) minutes ◦ Take the blood pressure in sitting position (assuming BP is 100/60)
◦ Rest mother for fifteen (15) minutes ◦ Get blood pressure at left lateral position (assuming BP is 90/60) ◦ Place mother in supine position ◦ Take the BP in supine position (assuming BP is 120/80)
Then compare values at left lateral and immediately supine
◦ Implication Positive Roll-over test if there is an: Increase in SYSTOLIC BP of 30 mmHg Increase in DIASTOLIC BP of 15 mmHg
Base line BP = Left Lateral BP Supine BP Difference
100/60 = 90/60 = 120/80 = 30/20
Therefore, this is positive for roll-over test Either systolic or diastolic, positive is positive Therefore, client has increased chance of developing Pregnancy Induced Hypertension
TRIAD OF PREGNANCY INDUCED HYPERTENSION Hypertension after twentieth (20th) week of Age of Gestation Proteinuria
◦ Greater than two-hundred fifty milligrams per deciliter (>250 mg/dl)
Edema
◦ Pathologic ◦ Physiologic
Two (2) General Classifications Pre-eclampsia Eclampsia PRE-ECLAMPSIA Mild Severe
Mild Pre-eclampsia Blood Pressure
◦ Positive to roll-over test ◦ But blood pressure can go as high as 140/90 to 150/100
Proteinuria
◦ Level of protein in urine is 500 mg/dl
Edema No associated signs and symptoms
Management of Mild Pre-eclampsia Bed Rest
◦ To conserve oxygen ◦ Due to constriction of vessels
Limit intake of salty foods ◦ Up to three (3) grams per day
Closer follow-up ◦ Weekly check-up
Severe Pre-eclampsia Blood Pressure
◦ 160/110 or more
Proteinuria Five (5) grams per liter Measured in twenty-four (24) hour urine output
Edema Other signs and symptoms:
◦ Severe headache ◦ Blurring vision due to retention of water going up to optic discs ◦ Fundoscopic examination Looking for papilledema
◦ Pulmonary edema Crackles Cough
◦ Oliguria Urine Output Less than four-hundred milliliters (< 400 ml) in a day Less than thirty thirty milliliters (< 30 ml) in an hour
◦ Epigastric pain Aura of an impending seizure
◦ Reason for Presence of Epigastric Pain Distention of capsule of liver due to edema Necrosis of pancreas Enzymes release digesting contents of intestine
◦ Vomiting
Due to increased intracranial pressure (▲ICP)
Management of Severe Pre-eclampsia Prevention of seizures
PHARMACOLOGIC MANAGEMENT Give Magnesium Sulfate (MgSO4)
◦ Drug of choice ◦ Can also cause decrease in Blood Pressure ◦ (Hydralazine is drug of choice for hypertension)
◦ Check deep tendon reflex ◦ Knee jerk If no reflex, hold magnesium sulfate Hyporeflexia
◦ Magnesium sulfate causes depression
◦ Check Respiratory Rate If less than twelve (12) to fourteen (14) respirations per minute, HOLD Magnesium sulfate causes INCREASED RESPIRATORY DEPRESSION
◦ Check Urine Output Magnesium Sulfate is eliminated through the urine
If urine output is low, Magnesium sulfate cannot be eliminated Loading Dose of Magnesium Sulfate Fourteen grams (14 g)
Four grams (4 g) via I.V. infusion pump Given for a duration of thirty (30) minutes This is painful to the blood vessels
Ten grams (10 g) via I.M. injection Five grams (5 g) on each buttock / gluteus
◦ Maintenance Dose Give at one to two grams (1 – 2 g) in one to two hours (1 hr. – 2 hrs.) Given via I.V. drip Continue forty-eight (48) hours after delivery Because there is post partum pre-eclampsia
◦ Antidote Calcium Gluconate One gram (1 g) via direct I.V.
Provide dim light room Limit Visitors Put up side rails Suction machine by bedside Don’t put anything in mouth if there is seizure Open collar Turn patient to side to eliminate saliva Concern is safety
ECLAMPSIA Positive for seizures Give additional medications:
◦ Diuretics Furosemide is the drug of choice
◦ Digitalis (digoxin) To promote contractility of heart without increasing heart rate Inotropic
Check pulse rate
◦ In Adults: If pulse rate is less than sixty beats per minute (< 60 BPM) – HOLD THE MEDICATION
◦ In children less than ten (10) years old
If pulse rate is less than eighty beats per minute
(< 80 BPM) – HOLD THE MEDICATION In both cases, patient will go into BRADYCARDIA IF MEDICATION IS NOT WITHHELD
◦ Potassium (K+) Prevents DIGITALIS TOXICITY
And USE OF POTASSIUM WASTING FUROSEMIDE
Before giving Potassium (K+) ◦ Before I.V. is in the vein, test for backflow ◦ Subcutaneous tissue necrosis ◦ Tissues get burned due to Potassium (K+)
Barbiturates Fast acting sedatives To arrest seizure Hydralazine For hypertension
HELLP SYNDROME HEMOLYSIS, ELEVATED LIVER ENZYMES, LOW PLATELET Due to necrosis of the liver Disseminated Intravascular Coagulopathy Because of increased pressure in the blood vessels
GESTATIONAL DIABETIS MELLITUS Two (2) values elevated in OGTT
DIET
◦ Maintain daily calorie intake of 1,800 to 2,200 kcal/day ◦ Refrain from eating simple sugars and saturated fats
EXERCISE
◦ Appropriate for Age of Gestation
PHARMACOLOGIC THERAPY ◦ Insulin
Drug of Choice
◦ Oral hypoglycemic agent is teratogenic
Insulin given is based on the weight of the client If client is sixty kilograms (60 kg)
◦ Give 1ų / kg / day ◦ Therefore, give sixty units
In a B.I.D. dosing ◦ Bigger portion is given in the morning ◦ 2/3 of 60 units = 40 units
Smaller portion is given in the evening ◦ 1/3 of 60 units = 20 units
The bigger portion – 2/3 portion or 40 units is composed of ◦ Regular Insulin Brief onset For immediate need Thirty (30) minutes to one (1) hour onset of action
Comprises 1/3 of 40 units
◦ Intermediate Insulin For later need Comprises 2/3 of the 40 units
Note: The bigger portion is given thirty (30) minutes prior to breakfast
For the smaller portion – 1/3 portion or 20 units ◦ 1 : 1 ratio of the regular : intermediate for 20 units 10 units for regular 10 units for intermediate
In drawing insulin Vacuum air First introduced to regular (clear)
◦ Draw this first
Then draw on the intermediate type
Hypoglycemia causes COMA
HEART DISEASE IN PREGNANCY Four (4) Functional Classifications of Heart Disease Class I
◦ Heart Disease is present ◦ But uncompromised
Class II
◦ Heart Disease is present ◦ Slightly compromised
Class III ◦ Heart Disease is present ◦ Markedly compromised
Class IV ◦ Heart Disease is present
Severely compromised
If you belong to Class I and Class II ◦ You can go through normal pregnancy
If you belong to Class III and Class IV ◦ You cannot go through normal pregnancy ◦ You are not a good candidate
In Heart Disease In Pregnancy Labor and delivery should be: Effortless Painless Pushless
◦ A vaginal delivery
EPIDURAL ANESTHESIA Upon active labor (3 cm) Check Blood Pressure Side effect is hypotension
No Oxytocin No Methergine No augmentation of labor All natural labor
General Anesthesia only given when crowning occurs ◦ If given early, this crosses the placenta and the effect is a decrease in the APGAR SCORE
POSITION OF CHOICE DURING LABOR Will deliver at these positions: Semi-sitting Semi-Fowler’s position ◦ Not lithotomy
Femoral vessels are obstructed
DELIVERY OF CHOICE Outlet forceps extraction – Vaginal In Caesarian Section
◦ Normal blood loss is 800 – 1,000 ml ◦ 1,000 ml blood loss is hemorrhage
In Normal Spontaneous Delivery ◦ Normal blood loss is 500 ml
500 ml blood loss is hemorrhag
PUERPERIUM Main Responsibility
◦ Achieve INVOLUTION Return of reproductive organs to pre-pregnancy state
Usually achieved after six (6) weeks
PRINCIPLES 1. PROMOTE HEALING Uterus
◦ At level of umbilicus ◦ After the delivery of the placenta
One (1) day after ◦ One (1) finger breadth below the umbilicus
Two (2) days after ◦ Two (2) finger breadths below the umbilicus
Three (3) days after ◦ Three (3) finger breadths below the umbilicus
Four (4) days after ◦ Four (4) finger breadths below the umbilicus
Five (5) days after ◦ Five (5) finger breadths below the umbilicus
Six (6) days after ◦ Six (6) finger breadths below the umbilicus
Seven (7) days after ◦ Seven (7) finger breadths below the umbilicus
Eight (8) days after ◦ Eight (8) finger breadths below the umbilicus
Nine (9) days after ◦ Nine (9) finger breadths below the umbilicus
Ten (10) days after ◦ Ten (10) finger breadths below the umbilicus or at the level of the symphysis pubis
Eleven (11) days after - Uterus at the pelvic cavity
After six (6) weeks, upon Internal Examination. . . ◦ If Uterus is midway between the umbilicus and symphysis pubis, this is ABNORMAL This means that there is something left inside
SUB-INVOLUTION or POST PARTUM HEMORRHAGE Uterus has not gone back to original size Caused by retained placental fragment
Rubra Day one (1) to day three (3) Day two (2) to day three (3) Bright red in color Serosa Day three (3) to day ten (10) Pinkish in color Actually, brown in color
Alba Day ten (10) until third (3rd) week up to sixth (6th) week post-partum
After six (6) weeks, THERE IS NO MORE LOCHIA
CHARACTERISTICS OF NORMAL LOCHIA Normal Odor
◦ Musty but not FOUL SMELLING ◦ Foul smell indicates infection
Color ◦ Should not be YELLOWISH ◦ Yellowish color indicates infection
Order of Appearance ◦ Should never be reversed ◦ Reversal in appearance indicates RETAINED PLACENTAL FRAGMENTS
LACTATIONAL AMENORRHEA Lactating Fully Not ovulating Six (6) months effectivity
TO BE EFFECTIVE There must be complete emptying of the breast without supplementation (baby receives no bottle feeding) Four (4) to six (6) months Start Supplementation
Normally, after eight (8) weeks or two (2) months, MENSTRUATION RETURNS If the mother is breastfeeding, it would take six (6) months BEFORE MENSTRUATION RETURNS
After three (3) to four (4) weeks, COITUS IS ALLOWABLE
2. PROVIDE EMOTIONAL SUPPORT TAKING IN First two (2) days post-partum Mother is very dependent for care for self and the newborn Rejecting rooming-in is NORMAL
TAKING HOLD After second day
◦ Mother is now independent of self care and newborn care ◦ Time of evidence of POST PARTUM BLUES / DEPRESSION IS OVERT
◦ If poor support system is present, this predisposes to POST PARTUM BLUES / DEPRESSION / PSYCHOSIS ◦ Brief Psychotic episode lasts for three (3) months
LETTING GO Completely accepted role as a new mother
3. PREVENTION OF POST-PARTUM. . . 3.1) MATERNAL HEMORRHAGE Early post-partum hemorrhage Occurs within the first twenty-four (24) hours after delivery
Uterine atony is most common cause Lacerations are the second most common cause Inherent clotting disorders occur: Thrombocytopenia Leukopenia
Late post-partum hemorrhage ◦ Occurs after first twenty-four hours of delivery
Common causes: ◦ Primary Cause Retained placental fragment/s
◦ Secondary Cause Hematoma (vaginal)
3.2) INFECTION Endogenous infection Normal flora causes infection These travel up the uterus
3.3) PERINEAL INFECTION On site of episiotomy
◦ Management involves antibiotic therapy
Surgical Management ◦ Remove suture ◦ Drain pus
Position in Semi-Fowler’s position
3.4) ENDOMETRITIS Infection of the lining of the uterus
◦ With maternal fever > 38° C (37.5°C is common due to dehydration) ◦ With foul-smelling vaginal discharge
With uterine or abdominal tenderness
Management for Endometritis Antibiotics Position
◦ Semi-Fowler’s position
Oxytocin is given ◦ Promotes contractions ◦ Promotes release of secretion
ENDOMETRITIS is a PRELUDE to THROMBOPHLEBITIS
3.5) THROMBOPHLEBITIS Most common site are the vessels of the LOWER EXTREMITIES Positive (+) for HOMAN’S SIGN
How is Homan’s Sign elicited? ◦ Ask patient to dorsiflex foot ◦ Upon lying supine, legs extended ◦ Stretching of the blood vessels causes pain on calf muscle (gastrocnemius muscle)
Management of Thrombophlebitis ◦ Antibiotics ◦ Anticoagulant Heparin Larger molecule than warfarin Less likely to enter breast milk
Discontinue breastfeeding whether heparin or warfarin is administered Antidotes
◦ For Heparin Protamine Sulfate
◦ For Warfarin Vitamin K
ESTABLISHMENT OF SUCCESSFUL LACTATION La leche Method
◦ When placenta is delivered ◦ There is decreased estrogen and progesterone
This indicates production of PROLACTIN
◦ Stimulation of acinar cells to produce milk and stored in the lobules ◦ Upon sucking, OXYTOCIN IS RELEASED This is the hormone responsible for the EJECTION OF MILK
HOW TO BREASTFEED Offer entire breast up to the areola Assume side lying position Hype up to suck whole nipple and areola Pull breast tissue away from the NOSE of the baby
Day 1 Start breastfeeding for five (5) minutes on each breast Day 2 Provide breastfeeding for six (6) minutes on each breast
Day 3 Provide breastfeeding for seven (7) minutes on each breast Day 4 Provide breastfeeding for eight (8) minutes on each breast
Day 5 Provide breastfeeding for nine (9) minutes on each breast Day 6 Provide breastfeeding for ten (10) minutes on each breast Stop and maintain ten (10) minute feeding per breast This would give a total of twenty (20) minutes of breastfeeding time
Important Concept! Breastfeeding is done on a per demand basis
1. CARDIOVASCULAR SYSTEM HEART As diaphragm rises, the heart is displaced laterally
Point of Maximum Impulse ◦ Normally located at Fifth Intercostal Space Midclavicular Line on the Left Side {5th ICS-MCL (L)} ◦ This shifts to Fourth Intercostal Space Lateral Axillary Line on the Left Side {4th ICS-LAL (L)}
◦ Exaggeration of first and second heart sounds {S1 (Lub) and S2 (Dub)} due to INCREASED CARDIAC OUTPUT
Appreciation of S3 (third heart sound; ventricular filling) due to INCREASED CARDIAC OUTPUT
Appreciation of a MURMUR, which is almost always SYSTOLIC (all pathologic) in natureInnocent in nature ◦ As soon as mother delivers placenta, excess fluid is absorbed or excreted, then the MURMUR DISAPPEARS
Blood Volume is INCREASED due to INCREASE IN WATER RETENTION
HIGHEST CARDIAC OUTPUT IN PREGNANCY Twenty-eight to thirty-two weeks (28-32 wks) Age of Gestation During labor and delivery Immediately postpartum Therefore, be careful and monitor pregnant cardiac patient
Supine Hypotensive Syndrome ◦ When mother assumes supine position, she develops hypotension ◦ Weight of uterus presses on the VENA CAVA This results into DECREASED VENOUS RETURN This results into DECREASED CARDIAC OUTPUT End result is HYPOTENSION
Therefore, SUPINE POSITION IN PREGNANCY IS NOT ALLOWABLE (particularly in the second and third trimester)
POSITION OF CHOICE ◦ Side-lying Left (so as not to impede the Vena Cava ◦ Left Lateral Position ◦ Sim’s Left Position With arm flexed Leg flexed Weight of uterus would be ON THE BED
2. HEMATOLOGIC CHANGES HEMODILUTION Due to increase in PLASMA VOLUME
CHANGES IN PLATELET Expected during Postpartum Due to blood loss, there is TRANSIENT INCREASE IN PLATELET COUNT This predisposes to THROMBOSIS due to platelet aggregation This would then predispose to EMBOLISM
Therefore, EARLY AMBULATION is NEEDED
WHITE BLOOD CELL LEVELS INCREASE (particularly in labor) LEUKOCYTOSIS is STRESS-INDUCED
◦ Increased by 20K to 30K
Therefore, DO NOT CORRELATE THIS TO INFECTION NO FEVER NO abdominal / uterine infection
3. RESPIRATORY SYSTEM Diaphragm is prevented from descending in inspiration on second and third trimester Tidal Volume is increased
◦ Lungs are easily filled ◦ Client tends to hyperventilate ◦ Therefore, RESPIRATORY ALKALOSIS OCCURS
This is manifested by: ◦ Tingling sensation on the lower ends of extremities ◦ Lightheadedness
Nursing Management ◦ Breathe through a paper bag or through cupped hands
During labor, there is increase in oxygen consumption by three-hundred percent (300%) ◦ When exhaling, pursed lip breathing is practiced during labor
Swelling of mucosa during estrogen ◦ Prone to epistaxis ◦ Therefore, caution in picking nose!
4. GASTROINTESTINAL TRACT 4.1) PICA Craving for food Unedible (i.e. rice grains) No reason for this May be due to hypersalivation If not checked, this causes vomiting
4.2) EPULIS OF PREGNANCY Effect on gums Swelling of gums due to INCREASED ESTROGEN
Therefore, CONTINUE TO USE SOFT BRISTLE TOOTHBRUSH
4.3) ESOPHAGUS Progesterone is a relaxant of smooth muscle
◦ Effect is on lower esophageal sphincter ◦ It is more relaxed
Pressure of Lower Esophageal Sphincter (LES) is less than pressure on Cardiac Sphincter (CS) ◦ If LES pressure is > CS pressure No regurgitation
◦ If LES pressure is < CS pressure ◦ There is HEARTBURN OR PYROSIS; SUBSTERNAL PAIN related to eating
Most common surgical complication of pregnancy is ACUTE APPENDICITIS! Right Upper Quadrant pain is not expressed during pregnancy or on flank as the appendix rises in pregnancy
Nursing Management Do not assume supine position after eating Gradual ambulation Small Frequent feeding
Due Progesterone’s relaxing effect on smooth muscles, there IS INCREASED GASTRIC EMPTYING TIME ◦ Water and electrolytes absorbed by walls ◦ This gives rise to hard stools ◦ This eventually leads to constipation
Management ◦ Increase fluid intake ◦ Provide high fiber diet
Tendency is to do valsalva maneuver ◦ This leads to hemorrhoids
Progesterone also decreases stretchability of vessels. ◦ This also causes hemorrhoids
5. RENAL OR EXCRETORY SYSTEM 5.1) Due to Progesterone There is relaxation of renal pelvis and the ureter
Therefore, URINE STAGNATION occurs in the URETER (no longer peristaltic)
Therefore, the PATIENT IS PRONE TO URINARY TRACT INFECTION
5.2) Glomerular Filtration Rate in Pregnancy Increased Cardiac Output Increased Glomerular Filtration Rate But absorptive capacity of nephrons is not increased (NO CHANGE IN ABSORPTION)
Therefore, the following will be spilled in the urine: ◦ Sugar ◦ Carbohydrates ◦ Protein
Carbohydrates in the urine is NORMAL Acceptable level of Carbohydrates in the urine
◦ Qualitative analysis ◦ Trace = +1 sugar
Protein in the urine is NORMAL Acceptable level of Proteins in the urine
◦ Trace = +1 Protein ◦ Or less than 250 mg / dl
If Protein level in the urine is greater than 250 mg / dl, CONSIDER PREGNANCY INDUCED HYPERTENSION
If you LOSE PROTEIN and RETAIN WATER, this leads to EDEMA ◦ This is Physiologic Edema ◦ This type of edema is normal and expected in pregnancy
No management for PHYSIOLOGIC EDEMA ◦ Supportive ◦ Leg raises
For Pathologic Edema ◦ Identify the cause of the edema ◦ Most common cause is PREGNANCY INDUCED HYPERTENSION
6. ENDOCRINE SYSTEM Hypertrophy is present in most of the endocrine system organs Thyroid Gland is hyperthrophied Increased production of thyroid hormones
Therefore, there is RISK FOR HYPERTHYROIDISM
◦ Patient may die when in labor with hyperthyroidism ◦ Thyroid Storm leads to arrhythmia ◦ Arrhythmia leads to DEATH
Therefore, monitor so that client goes EUTHYROID (with normal thyroid hormonal level)
7. NEUROLOGIC SYSTEM This is the only system UNAFFECTED during pregnancy The following are normal during pregnancy:
◦ Blurring of vision
Headache
8. MUSCULOSKELETAL SYSTEM 8.1) PLACENTA IS CAPABLE OF PRODUCING RELAXIN Relaxes pelvic joints Therefore, the pelvis is more movable
8.2) DIASTASIS RECTI Separation of rectus abdominis muscle Only fascia remains in between This is normal Rectus abdominis muscle goes back after pregnancy (coarctate)
8.3) PHYSIOLOGIC LORDOSIS Known as the PRIDE OF PREGNANCY Increased outward curvature
◦ There is back pain
Nursing Management ◦ Do PELVIC ROCKING Place direct pressure on lumbar area
◦ Prevent supine position Increases pressure on the spine
◦ No analgesics
FETAL CIRCULATION PLACENTA Functions of the Placenta Mnemonic is NIMEE N is for: NUTRITION or NIDATION
◦ Supplying nutritional requirements of the fetus
◦ Nutrients and oxygen exchanged ◦ THE BLOOD IS NOT EXCHANGED ◦ Modes of Exchange Active transport from mother to baby Diffusion Pinocytosis
I is for: IMMUNOLOGIC ◦ If not pregnant, all foreign matter – antigens are rejected ◦ Baby is a foreign matter ◦ But immunologic function of the placenta removes the MAJOR HISTOCOMPANITIBILITY COMPLEX TYPE 2 (MHC TYPE 2) ◦ This is responsible for rejecting the foreign body
M is for: METABOLIC FUNCTION ◦ In Fetal Circulation Nutrient exchange occurs NO PORTAL CIRCULATION EXISTS Liver is bypassed as METABOLISM (by the liver) is NOT NEEDED
E is for: ENDOCRINOLOGIC ◦ Hormones are secreted only during pregnancy: Human Placental Lactogen Human Chorionic Gonadotropin Relaxin
E is for: EXCRETORY Metabolites excreted by Placenta and NOT BY THE KIDNEY NOR THE LIVER
FETAL CIRCULATION Starts from the placenta Connected to the uterus Decidua is bathed by UTERINE ARTERY Uterine Artery ► Sinuses of the Placenta ►Exchange of nutrients ►Umbilical vein
Placenta ▼▼▼ Umbilical vein (composed of two arteries and one vein – AVA) ▼▼▼ Liver ▼▼▼ Ductus Venosus (First Shunt)
▼▼▼ Inferior Vena Cava ▼▼▼ Right Atrium ▼▼▼ Foramen Ovale (Second Shunt) ▼▼▼ Left Atrium ▼▼▼ Left Ventricle
▼▼▼ Aorta ▼▼▼ ▼▼▼ To upper half of the fetal body only Upper Extreme Brain Heart Pulmonary
Upper part of the GUT ▼▼▼ ▼▼▼ Then this blood is recollected ▼▼▼ with less oxygen and then it ▼▼▼ goes to the ▼▼▼ Superior Vena Cava
▼▼▼ Right Atrium ▼▼▼ Right Ventricle ▼▼▼ Pulmonary Artery (but lungs are collapsed; Surfactant inadequate and amniotic fluid is present) ▼▼▼ Ductus Arteriosus
▼▼▼ Descending Aorta ▼▼▼ Supply the lower half of the fetal body ▼▼▼ ▼▼▼ Blood is recollected ▼▼▼ Hypogastric Artery ▼▼▼ Umbilical Artery ▼▼▼ Placenta
SHUNTS When the baby is delivered, the shunts are normally removed ◦ Ductus Venosus ◦ Foramen ovale
Two (2) types of Closure Functional Closure Anatomic Closure
FORAMEN OVALE Closed functionally immediately after birth or IMMEDIATELY AFTER CORD IS CLAMPED Anatomically, it can persist up to one (1) year after delivery
◦ Therefore, in auscultation in twenty-eight (28) day old baby There is a MURMUR This is Normal This is NOT A PATHOLOGIC MURMUR It is a SYSTEMIC / INNOCENT MURMUR
◦ A PHYSIOLOGIC MURMUR IN NEONATES
DUCTUS ARTERIOSUS Functional Closure ◦ Ten to ninety-six hours (10 – 96 hrs) after birth or approximately four (4) days
Anatomically ◦ Two to three months (2 – 3 mos.)
DRUGS TAKEN DURING PREGNANCY NSAIDs Indomethacin ◦ Not advisable ◦ Causes premature closure of the Ductus Arteriosus ◦ Not compatible with life ◦ No supply to the lower half of the body of the fetus PARACETAMOL IS ALLOWED
ASPIRIN Causes persistence of Ductus Arteriosus even after delivery No functional / anatomic delivery of Ductus Arteriosus Important Concept!
◦ Stop taking about four (4) weeks prior to confinement
ASSESSMENT OF FETAL MATURITY AND WELL-BEING 1. MATERNAL HISTORY AND PHYSICAL EXAMINATION 1.1) First thing to ask is the LAST MENSTRUAL PERIOD Purpose is to IDENTIFY THE AGE OF GESTATION
1.2) What are History of Previous Pregnancy: NSAID? Postpartum complication? Infection?
1.3) Past Medical History Diabetes Mellitus? Gestational Diabetes? Hypertension?
2. FETAL HEART TONE Easiest method to assess for fetal wellbeing Very reliable indicator of oxygenation of the fetus If FHT is heard
◦ Fetus is alive ◦ THIS IS AN ALL OR NONE RESPONSE
NORMAL
◦ 120 –160 beats per minute
If greater than 160 ◦ Tachycardia
If less than 120 ◦ Bradycardia
Be able to assess that sound you hear in the mother is the FHT In the mother’s abdomen, you can hear:
◦ BORBORYGMIC SOUNDS
Hunger sounds
◦ UMBILICAL SOUFFLE When the blood in the placenta enters the umbilical vein, this coincides with the Fetal Heart Tone
But FHT should be DISTINCT
Fetal Heart Tone sound TUG – TUG – TUG
Umbilical Souffle Sound SHHH – SHHH – SHHH This is the sound of the gush of blood
◦ UTERINE SOUFFLE Sound heard when blood enters uterine artery This coincides with the heartbeat of the mother
IDEAL WAY TO TAKE THE FETAL HEART TONE Use the bell of the stethoscope
◦ Purpose is for greater amplification
Hand / Dominant Hand ◦ On area being auscultated
Non-Dominant Hand
◦ Palpates radial pulses for the mother
Therefore, you can correlate ◦ FETAL HEART TONE IS DISTINCT TUG – TUG – TUG – TUG
◦ Radial pulse of the Mother is
Tug - - - - - - Tug - - - - - - Tug
FETAL MOVEMENT Two (2) schools of thought
◦ Cardiff Count to Ten ◦ Sandovsky Method
CARDIFF COUNT TO TEN Normal Fetal Movement
◦ At least one (1) movement every five (5) to six (6) minutes ◦ About ten (10) to twelve (12) movements per hour
First Instruction ◦ Instruct the client to eat LIGHT MEAL one (1) hour before monitoring for fetal movement
Have short walk or massage abdomen as baby may be asleep or is hungry Ask mother to assume left lateral position A clock must be at the bedside with pencil and paper Dominant hand of mother palpates most prominent part of abdomen Note for any fetal movement
FETAL MOVEMENT SHOULD BE ASSESSED WHEN THERE IS QUICKENING (AT TWENTYFOUR MONTHS AGE OF GESTATION ONWARDS)
Mother notes for ten (10) fetal movements and NOTES THE TIME THAT THE TEN (10) FETAL MOVEMENTS HAVE BEEN COMPLETED ◦ Should be completed in one (1) hour ◦ Approximately five (5) movements in thirty (30) minutes
You MUST get at LEAST ONE HALF OF NORMAL
Therefore, AT LEAST FIVE (5) FETAL MOVEMENTS PER HOUR IS ACCEPTABLE
SANDOVSKY METHOD Same procedure as in Cardiff Count to Ten Mother monitors fetal movement three (3) times a day These are done:
◦ After breakfast ◦ After lunch ◦ After dinner
Normal You should appreciate two (2) to three (3) fetal movements in one hour
OTHER WAYS TO ASSESS: DIAGNOSTICS AMNIOCENTESIS Best done at sixteen to eighteen (16 – 18) weeks Age of Gestation or during second (2nd) trimester This is the time when the baby is SMALL and there is MUCH AMNIOTIC FLUID
Information Obtained: A) FETAL LUNG MATURITY Analyzed for lung surfactant: Dipalmytoyl Phosphatidylcholine L : S Ratio
◦ Lecithin : Sphingomyelin Ratio
Lecithin is a specific component of lung surfactant
◦ Lecithin should be greater than Spinglomyelin ◦ Normal Ratio is 2L : 1S
If there is anticipated premature delivery, amniocentesis is done to know if delivery is viable
PHOSPHATIDYL GLYCEROL (PG) Most potent of all lung surfactants Usually appreciated at amniotic fluid at THIRTY-FOUR to THIRTY SIX (34 – 36) WEEKS AGE OF GESTATION
Therefore, it is safe to deliver fetus if Phosphatidyl Glycerol is present There is decreased risk of respiratory distress
POLYHYDRAMNIOS Amniotic fluid greater than 2,000 ml
◦ A teratogenic effect
Therefore, remove part of amniotic fluid
IDENTIFICATION OF GENETIC OR CHROMOSOMAL PROBLEM HOW TO PREPARE THE CLIENT FOR AMNIOCENTESIS
Explain what to do to the client Get Consent Remember, CONSENT IS NEEDED as this procedure is INVASIVE! Client must have I. V. fluid
◦ Plain Normal Saline Solution ◦ Side drip of Tocolytic to relax the uterus
Ask client to void before the procedure so as not to puncture bladder ◦ Ultrasound-guided procedure ◦ Needle should not puncture the placenta
Abdomen is prepared aseptically
Specific Site ◦ Pocket of abdomen containing highest amount of Amniotic Fluid ◦ Done by OBSTETRIC SONOLOGIST
Needle Inserted ◦ Local anesthesia ◦ Abdominal wall through the uterus to amniotic sac
Post Procedure ◦ ◦ ◦ ◦ ◦
Check Vital Signs (every fifteen (15) minutes) Check Blood Pressure Check Fetal Heart Tone Client then rests for two (2) to three (3) hours Mother is then sent home
DISCHARGE INSTRUCTIONS ◦ Note for UTERINE TONE ◦ Note for Fetal Activity ◦ Client may be: Hyperactive In distress
Hypoactive In distress
◦ Note for vaginal bleeding or spotting ◦ Vaginal spotting is acceptable
DANGER SIGNS Persistent uterine contraction Hyper / Hypoactive Vaginal Spotting to Bleeding
◦ Therefore, ask mother to come back if she observes any of the above signs
MATERNAL SERUM ALPHA FETOPROTEIN A special kind of protein produced in the yolk sac of the liver of baby / fetus Specimen is blood Consent is needed
Normal value of Maternal Serum Alpha Feto Protein (MS AFP) ◦ 2.0 – 2.5 MOM (measurements of the mean)
If MS AFP is higher than normal, THERE IS A NEURAL TUBE DEFECT: ◦ Spina bifida ◦ Meningocoel ◦ Myelomeningocoel
Anencephaly
If MS AFP is lower than normal, THERE IS DOWN’S SYNDROME Therefore, you must be able to know exact Age of Gestation
Fifteen to Twenty (15 – 20) weeks Age of Gestation is the IDEAL TIME FOR MS AFP or during the SECOND (2nd) TRIMESTER, not on the First or the Third Trimesters If early high result
◦ Yolk sac and liver gives false elevated result
If late low result
◦ Liver only gives false low result
CHORIONIC VILLUS SAMPLING (CVS) Get part of chorionic villi from the placenta Done at nine to twelve (9 – 12) weeks Age of Gestation Approach is INTRAVAGINAL Ultrasound-guided
A part of chorionic villi near maternal attachment will be suctioned to the catheter for KARYOTYPING and GENETIC ANAL
Purpose of this procedure is for detection of genetic and chromosomal problems Nursing Responsibility
◦ Bleeding is common in CVS ◦ Instruct mother to observe SPOTTING to BLEEDING ◦ Ask mother to come back if bleeding occurs
Therefore, not much done; increases chance of abortion or fetal loss
PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS) Also known as CORDOCENTESIS Get sample Ultrasound-guided Sonologist identifies umbilical vein
◦ Vein has larger lumen than the artery
Catheter is inserted Approach is through the abdomen
Information obtained: ◦ For identification of blood incompatibilities ◦ For exchange transfusion ◦ For isoimmunization Needed in instances of an Rh+ baby and an Rhmother
ULTRASOUND Types of Ultrasound Transabdominal Ultrasound Transvaginal Ultrasound
TRANSABDOMINAL ULTRASOUND Ask the client to FILL BLADDER Full bladder will push uterus to pelvic cavity for better visualization at abdomen
ULTRASOUND IN FIRST TRIMESTER Information obtained: Confirmation of Pregnancy
◦ (+) cardiac movement ◦ (+) yolk sac ◦ (+) Fetal Heart Tone
Identification of Ectopic Pregnancy ◦ Fallopian tube is PERISTALTIC
◦ Therefore, look at the uterus
◦ If the uterus is empty and positive (+) for pregnancy test, then there is pregnancy outside or ECTOPIC PREGNANCY
Identification of Intrauterine Device (IUD) in Place ◦ Intrauterine Device Has 97% protection Has 3% failure rate
◦ If IUD is in place and pregnancy occurs, advice the client to LET THE IUD STAY IN PLACE ◦ IUD will attach to the fetal membrane ◦ If taken out, there is greater chance of SPONTANEOUS ABORTION
Identification of the H-MOLE ◦ Ultrasound characteristic of H-Mole SNOW STORM APPEARANCE In a dark background there is a speck of white
There are vesicles
ULTRASOUND IN THE SECOND AND THIRD TRIMESTER Information obtained: Location of Placenta ◦ Placental Localization
Growth of the Fetus Amount of Amniotic Fluid Fetal Position and Fetal Presentation Sex / Gender of the baby
◦ Determinable at sixteen (16) weeks of gestation ◦ Ideal time is twenty-eight (28) weeks
Congenital / Chromosomal Problems
◦ Determined by three-dimensional (3D) ultrasound
TRANSVAGINAL ULTRASOUND Ask client to void
BIOPHYSICAL SCORE Has five (5) parameters (including NonStress Test or NST) Modified Biophysical Score
◦ Has four parameters only
Uses ULTRASOUND
Criteria / Parameters observed ◦ Fetal Breathing Two (2) is the highest score for this parameter
◦ Fetal Movement Two (2) is the highest score for this parameter
◦ Fetal Muscle Tone Flexion and extension in utero Two (2) is the highest score for this parameter ◦ Amniotic Fluid Index Done for a period of thirty (30) minutes Baby’s breathing is not spontaneous Two (2) is the highest score for this parameter
Perfect score is 8/8
◦ This means that the baby is in the best possible health
Before, Biophysical Score includes the NonStress Test Non-Stress Test
◦ For fetal heart activity ◦ With this parameter added, the perfect score in BPS becomes 10/10
NON-STRESS TEST Uses CARDIOTOGORAPH (CTG) TRACING No stressor on part of the baby
Stressor is the contraction of the uterus There should be NO CONTRACTION Compare
◦ Fetal Heart Tone and Fetal Movement If baby moves, FHT INCREASES!
With two (2) transducers placed near FHT at fundus of uterus Leopold’s maneuver Water soluble lubricant
◦ KY jelly amplifies FHT
CRITERIA TO SAY NST IS NORMAL Period of Observation should be ◦ Greater than or equal to twenty (20) minutes
You must get at least two (2) accelerations in twenty (20) minutes Acceleration should be at least fifteen (15) beats above baseline
Duration of acceleration should be ◦ Greater than or equal to fifteen (15) seconds ◦ One (1) small square = one (1) second
Therefore, IF ALL CRITERIA ARE MET, NONSTRESS TEST IS NORMAL
If NST is NORMAL – IT IS REACTIVE Therefore, the chances of fetal survival is greater than 99% in the next week You can assure the mother
If NOT ALL CRITERIA ARE MET (i.e. Criteria No.3 with 10 beats per minute only), Repeat NST after two (2) to three (3) hours
If NST is NON-REACTIVE, it is ABNORMAL
CONTRACTION STRESS TEST (CST) Best done when mother is at thirty-eight (38) weeks Age of Gestation Done when NST is NON-REACTIVE Then, proceed with Contraction Stress Test If CST could not be withstood by baby, IT NEEDS IMMEDIATE DELIVERY Introduce a STRESSOR – CONTRACTION if ABNORMAL CST
OXYTOCIN CHALLENGE TEST Rub nipples
◦ Nipple stimulation if uterus is NOT contracting
When assessing ◦ Hide your thumb
If you are a male so as not to be sued for sexual harassment
TWO (2) ABSOLUTE CONTRAINDICATIONS FOR CONTRACTION STRESS TEST If client is premature (Biophysical Score is used instead) History of problem in the placenta (placentation)
NIPPLE STIMULATION ◦ Give warm pack / warm soaks for ten (10) minutes prior to stimulation to increase circulation / vascularity ◦ Explain procedure ◦ Start ◦ Four (4) cycles per stimulation ◦ 1, 2, 3, 4 stimulations REST x4
First Cycle
◦ If after these and there are NO CONTRACTIONS ◦ Stop and rest for two (2) to four (4) minutes ◦ Then stimulate Up to four (4) cycles
◦ If NO CONTRACTIONS AFTER THE FOURTH (4th) CYCLE Stop stimulation Proceed with Oxytocin Challenge Test
OXYTOCIN CHALLENGE TEST Give diluted form of oxytocin
◦ Five units (5U) or ½ampule + 1 liter D5LR or D5H2O
Give
at a titrating dose Start at ten to twelve (10-12) drops per minute to a maximum of forty (40) drops per minute Observe for Uterine Contraction
Wait for two (2) consecutive uterine contractions Stop Oxytocin Challenge Test if two (2) uterine contractions are obtained Now compare Uterine Contractions with Fetal Heart Tone
NEGATIVE ◦ In the presence of uterine contraction, tracing is NEGATIVE FOR DECELERATION
Vagus Nerve ◦ Parasympathetic Stimulation gives rise to bradycardia
Carotid Stimulation results into ◦ Bradycardia ◦ Hypotension
Abnormal if POSITIVE (+) FOR DECELERATION
INTERVENTIONS If in labor: Turn client to left lateral position Stop oxytocin immediately ◦ No contractions are wanted
Give oxygen to mother ◦ Rate is 8 – 10 liters per minute
Hydrate with plain water ◦ No incorporation of oxytocin to increase circulating blood volume ◦ Mother is on NPO during labor and there could be DEHYDRATION
ADH secretion is increased to conserve water ◦ ADH is released from the posterior pituitary ◦ Oxytocin is released from the posterior pituitary ◦ Cross reaction of ADH and Oxytocin in the Uterus ◦ ADH binds in OXYTOCIN RECEPTORS in Uterus resulting to CONTRACTION ◦ Therefore, hydrate so as not to increase ADH secretion
If variable deceleration is >10 minutes, then CAESARIAN SECTION may be NECESSARY
LATE DECELERATION Occurs before contraction ends Has a late recovery Baseline is changed Lower than original baseline Significance: ◦ UTEROPLACENTAL INSUFFICIENCY is present
Management ◦ Hydrate ◦ Give oxygen ◦ Stop oxytocin
Placenta and Uterus are compromised ◦ Therefore, this is an indication for OUTRIGHT ABDOMINAL DELIVERY ◦ Do outright Caesarian Section
PRE-NATAL ASSESSMENT In the Ideal Setting: At zero to twenty-eight weeks (0 – 28) Age of Gestation
◦ Ask client to come back every four (4) weeks
At twenty-eight to thirty-six weeks (28 – 36) Age of Gestation ◦ Ask client to come back every two (2) weeks
At thirty-six (36) weeks onwards Ask client to come back every week
DOH RECOMMENDATION One (1) pre-natal check-up per TRIMESTER Three (3) pre-natal check-ups during the entire course of pregnancy
If high risk Below 18 years old Above 35 years old Greater than Gravida 5
◦ Due to higher chances of maternal bleeding after delivery
Problem in placentation (location)
History of Maternal illness ◦ Hypertension ◦ Diabetes mellitus ◦ Cardiac Problems
Clinical check-up should be performed every week!
Auscultate the lungs on the first visit Nursing history has physical examination
◦ ◦ ◦ ◦
This is done by the nurses Not weigh Baby is sleeping contentedly Baby will cry
Changes in heart rate NO IPPA IN PEDIATRIC PATIENTS
Get Maternal History of Client Laboratory Examinations COMPLETE BLOOD COUNT Hemoglobin Hematocrit Platelet Rh and ABO blood typing
Important Concepts! Asians NOT COMMONLY Rh Caucasians are COMMONLY Rh
BLOOD NOMENCLATURE ABO Typing ◦ Type A, B, O ◦ A or B antigens
Rh Typing ◦ Rh (C, D, E) ◦ Three antigens C D E
◦ In incompatibility, the concern is the D antigen
Rh Mother is RhFather is Rh+ No D antigens ▼▼▼ Rh- or Rh0 ▼▼▼ (zero for D) ▼▼▼ ▼▼▼▼▼▼▼▼▼▼▼▼▼ Baby is Rh+ or Rh(D) Antigen D is present in the blood
The first pregnancy is spared The first baby is born Blood enters mother’s circulation
Therefore, mother PRODUCES ANTI-D antibody
Interaction During time of delivery when the placenta starts to detach from maternal attachment Abortion / Dilatation and Curettage Some fragments of placenta are retained in the uterus Ancillary Procedures like AMNIOCENTESIS Interaction of blood of baby entering mother occurs and stimulates antigenantibody reaction
Second Pregnancy Anti-D antibody of mother hemolyzes the Antigen D of second baby
◦ This results into erythroblastosis fetalis or death of the RED BLOOD CELLS ◦ Second baby would have SEVERE ANEMIA ► HEART FAILURE ►ANASARCOUS►DEATH
RHOGAM Gamma globulin A pre-formed antibody Given within seventy-two (72) hours If to undergo amniocentesis
◦ Rhogam is given before the procedure
If mother undergoes abortion ◦ Rhogam is given within seventy-two (72) hours after abortion
If pregnant now
◦ Give at twenty-eight to thirty-two (28 – 32) weeks Age of Gestation ◦ to Rh- mother REGARDLESS OF Rh of Baby
RhoGam
is repeated prior to term at forty (40) weeks RhoGam has a half life Rhogam may be out of circulation
COOMB’S TEST Two (2) types Direct Coomb’s Test Indirect Coomb’s Test
DIRECT COOMB’S TEST Concerns the Baby Identify if RBC of baby has hemolysis and has attached antibody Therefore, sensitization has occurred on the mother
INDIRECT COOMB’S TEST Concerns the mother Identify for titer of antibody
◦ ◦ ◦ ◦
Get blood sample Identify titer of Anti-D Zero titer if Rh+ If Rh- individual 1 : 8 or 1 : 16
If titer is less than 1 : 8 this means that MOTHER IS NOT YET SENSITIZED ◦ Therefore, blood of the mother is FREE OF ANTI-D antibody
There is a need for RhoGam
If
titer is greater than 1 : 16 this means that there is SENSITIZATION ◦ It has ANTI-D antibody ◦ Then, RhoGam is NOT needed ◦ RhoGam CANNOT REVERSE SENSITIZATION
Situation Mother is Type O Rh Baby is Type A Rh+
Question What type of blood do you give?
Answer Give type A blood
Rationale Hemolysis is present Baby has anti-D that is why there is hemolysis If Rh+ is given
◦ There is continuous antibody given – there is confirmed hemolysis ◦ Therefore, give Rh-
ALWAYS GIVE THE BLOOD TYPE OF THE MOTHER (as far as Rh is concerned)
If mother is Rh+ and father is Rh+, then the baby is Rh+ and there is no problem
Type O blood causes hemolysis If baby is type A, B, AB
Question What type of blood in mother will cause hemolysis in ABO? Answer Type O Question What type of blood will be given to the baby if there is ABO incompatibility? Answer Blood type of mother
Most common cause of PATHOLOGIC JAUNDICE is ABO INCOMPATIBILITY Pathologic Jaundice is prolonged jaundice Normal Value of Bilirubin
◦ 15 mg / dl
If greater than 15 mg / dl, transformation is needed ABO INCOMPATIBILITY is protective against Rh INCOMPATIBILITY
◦ If Mother is type O
◦ If Baby is type A
RBC carries Rh(D) ◦ RBC of baby contains D antigen ◦ Since hemolysis has already occurred, Anti-D of mother will no longer hemolyze any RBC with Anti-D
APGAR – SCORING SIGN
O
1
2
HR
absent
<100
>100
Respirator effort
absent
Slow and irregular
Good and strong, loud cry
Some flexion of extremities
Active motion. General flexion
Activity: flaccid muscle tone Reflex irritability
No response to Weak cry or stimuli grimace
Cry: vigorous
appearance
Blue, pale
Completely pink
Body pink, extremities
Fetal anatomy and physiology 1. Fetal circulation – four intrauterine structures that differ from extrauterine structures. a. umbilical vein – carries oxygen and nutrient-enriched blood from placenta to ductus and liver. b. ductus venosus – connects to inferior vena cava; allows most blood to bypass liver.
c.Foramen ovale – allows fetal blood to bypass fetal lungs by shunting it from right atrium into left atrium. d. Ductus arteriosus – allows fetal blood to bypass fetal lungs by shunting it from pulmonary artery into aorta. e. Umbilical arteries – allows return of deoxygenated blood to the placenta.
2. Umbilical cord – extends from fetus to center of placenta: usually 50 cm (18-22 inches) long and 1-2 cm (1/2 – 1 inch) in diameter. Contains: a. Wharton’s jelly – protects umbilical vessels from pressure, cord “kinking” and interference with fetal-placental circulation. b. umbilical vein – carries oxygen and nutrients from placenta to fetus.
c. Two umbilical arteries – carry deoxygenated blood and fetal wastes from fetus to placenta. *absences of one artery indicates need to rule out intraabdominal anomalies.
3. Characteristics of fetal blood b. Fetal hemoglobin (HbF) a.1 higher oxygen-carrying capacity than adult hemoglobin a.2 releases oxygen easily to fetal tissues a.3 ensures high fetal oxygen a.4 normal range at term: 85ml/kg body wt. Hct: 38%-62%, average 53%: RBC 3-7 million, average 4.9 million/U.
Extrauterine adaptation: task 2. Establish and maintain ventilation, successful gas transfer- requires patent airway and adequate pulmonary surfactant. 3. Modify circulatory patterns – requires closure of fetal structures. 4. Absorb and utilize fluids and nutrients 5. Excrete body wastes 6. Establish and maintain thermal stability
A.
Admission assessment of normal, termneonate 1. color and reactivity 2. general appearance, symmetry 3. length and weight 4. head and chest circumferences 5. vital signs:
Criterion Vital signs
Average values
Heart rate
120-140/min, irregular, especially when crying, and functional murmur
respiratory
30-60/min with short periods of apnea, irregular; vigorous and loud cry.
temperature
Stabilizes about 8-10 hr after birth; 36.5 -37 degree centigrade
Blood pressure
60-80/40-50; varies with change in activity level
Criterion
Average values
Measurements weight
3400g(71/2 lbs); range: 5 lb 8 oz – 8 lbs 13 oz
Length
50 cm (20 inches); ranges: 18 – 22 inches
Chest circumference
2 cm (3/4 inch) less than head circumference
Head circumference
33 – 35 cm (13 -14 inches)
Criterion
Average values
General assessment Muscle tone
Good tone and generalized flexion; full range of motion; spontaneous movement
Skin color
Mottling, acrocyanosis, and physiological jaundice; petechiae, milia, mongolian spotting, lanugo, and vernix caseosa
Head
Moulding of fontanels and sutute spaces; one-fourth of body length
Hair
Silky, single strands, lies flat; grows towards face and neck
eyes
Edematous eyelids,
nose
Appears to have no bridge
1.
2.
3.
4. 5.
Altered health maintenance related to separation from maternal support system Impaired skin integrity related to umbilical stumps; incontinence of urine and meconium stool. Ineffective airway clearance related to excessive mucus Pain related to environmental stimuli Ineffective thermoregulation related to immature temperature regulation mechanism
1.
Goal; promote effective gas transport a. maintain patent airway – to promote effective gas exchange and respiratory function. b. Position: right side-lying, head dependent (gravity drainage of fluid, mucus) c. suction prn with syringe for mucus
2. Goal: establish/maintain thermal stability a. Avoid chilling – to prevent metabolic acidosis b. dry, wrap c. place in heated crib d. monitor vital signs hourly until stbale
3. goal: promote bonding. a. encourage parent-infant interaction (holding, touching, eye contact, talking to infant) b. encourage breastfeeding within 1 hr of birth c. encourage parent participation in infant care to develop confidence and competence in caring for newborn
Sleeping – almost continual (wakes only to feed) or 12 – 16 hr daily Feeding – from every 2-3 hr to longer intervals; establish own pattern Weight loss – 5% - 10% in first few days regained in 7-14 days Cord care – drops off in 7 – 10 days Physiologic jaundice – occurs 24- 72 hr after birth. Non pathologic, need for hydration
Age
Bottle-fed
breastfed
implications
1 day
Meconium
Meconium
Absences may indicate obstruction or atresia
2-5 days Greenish yellow, loose
Greenish yellow, loose, frequent
At any time
> 5 days Yellow to brown, firm, 2 -4 daily foul odor
Bright golden yellow, loose, 6 -10 daily
Dairrhea – greenid\sh, mucus Constipation – dry, hard stools
GOOD DAY!
THANK YOU..GOOD LUCK..
1.Which phase of the menstrual cycle is characterized by a surge in luteinizing hormone (LH) from the pituitary gland? A.Proliferative B.Menstruation
C. Ichemic D. Secretory
2. At the beginning of menstruation, the following physiologic changes occurs, except. A. an ovulation begins to mature in the graafian follicle B. estrogen and progesterone are at their lowest level C. luteinizing hormone are at its peak D. follicle stimulating hormone has just begun to rise.
Situation: Mrs. Flor de Luna is on her fifth month of pregnancy.
3Which of the following fetal development has been achieved during the fifth month of gestation? A. ossification of the bone is completed B. Mrs. De Luna can feel her baby’s movement C. Vernix caseosa is developed D. Heartbeat is audible by Doppler
4. When Mrs. De Luna enters the seventh month of pregnancy, how often will be her pre-natal check- up? A. once a week B. as often as she desires D. twice a month
c. once a month
5. What level of the abdomen can be fundic height be palpated at 5 months gestation? A. midpoint between the symphysis pubis B. symphysis pubis C. midpoint between umbilicus and xiphoid D. umbilicus
Situation: Mrs Brenda Mage, 24 year old, consulted at the health center because of nausea and vomiting. She claimed that she missed her menstruation for 2 months and her LMP was March 1.
6. Which of the following is a probable sign that Mrs. Mage is pregnant? absence of menstruation softening of the cervix C. nausea and vomiting D. Breastc hanges
7. Which of the following terms refers to the first pregnancy? A. Primipara B. Nullipara
c. primigravida d. nulligravida
8.How many weeks AOG will Mrs. Mage be on her next prenatal visit, which is scheduled on may 15. A. 13 – 14 B. 12 – 13
C. 10 – 11 D. 11 – 12
9. When will be the EDC of Mrs. Mage? A. December 8 B. December 7
c. December 9 d. January 8
10. Which sign refers to the softening of the lower uterine segment? A. Chadwick’s B. Hegar’s
c. Culkin’s d. Goodel’s
Situation: Nicole claims to be amenorrheic for 1 month. She consults at the lying –in clinic.
11. What hormone is excreted in the urine that serves as the basis for most tests for pregnancy? A. HCG B. FSH
c. progesterone d. estrogen
12. Nicole complains of urinary frequency. Which of the following be the best response of the nurse? A. “ limit your fluid intake to 2 liters per day” B. “ I would not worry if I were you, it is not unusual.” C. “ just use panty shields so you will be dry and comfortable.” D.“ this is expected because of the compression of your ascending uterus.”
13.Which of the following intervention will be the most helpful to Nicole in adapting to her pregnancy? A. encourage her to attend pregnant mothers’ classes B. advise to have a regular pre-natal check-up C. involve her husband in planning for her needs D. assist her in exploring and expressing her feelings
Situation: Marla is 25 year old G2P1, full term is rushed to the ER due to passage of watery vaginal discharge.
14. Which of the following interventions will be the immediate action of the nurse? ◦
take her fetal heart tone c. start an intravenous fluid B. monitor her vital signs d. place her on left lateral position
15. The nurse observes the vaginal discharge of Marla. Which characteristics of the amniotic fluid that the fetus is in distress? volume is about 1 liter c. greenish mucus - tinged d. colorless
16. Which of the following is not a sign of true labor? A. intensity of contractions increases gradually shorten B. intervals between uterine contractions increases C. cervical dilation and effacement increase D. uterine contractions are more frequent and of shorter duration
17.What is the most fatal complication of PROM to the fetus? A. delayed onset of labor B. ascending infection
c. dehydration d. cord prolapsed
18. Marla is instructed to count and record fetal movement every hour. How many movement per hour indicates that Marla’s baby has a healthy status/ A. 2 B. 4
c. 5 d. 3
Situation: Aurora is on her 3rd post normal spontaneous delivery.
19. She complains of inability to defecate inspite of taking regular meals and frequent ambulation. The following are recommended to reestablish her regular defecation, which one is least priority/ A. milk of magnesium 45 ml diet B. adequate fluid intake extraction
c. high roughage d. do manual
20. She must report to the nurse if she observes that her lochial discharge: A. contains mucus and particles of cellular debris B. is bright red on the 5th day post partum C. has a musty odor D.disappears after the third week
21. She remarks, “Do you think I have milk for my baby?” This signals what phase of the puerperium ? A. post partum blues c. taking -hold B. post partum psychosis d. taking –in
22. which of the following will best initiates the secretions of milk? A. use of breast pump in expressing milk B. manual breast expression C. adequate intake of fluid D. allow infant to suck each breast alternately
23.In the physiology of lactation, the oxytocin hormone functions to: A. stimulates lactogenesis c. suppression of milk B. produces more milk d. alters secretion of milk
Situation: Andrea is a newly registered nurse who is assigned at the OB ward where some nursing students are having their related learning experience on the concept of pregnancy.
24. One student asks Andrea to discuss what a zygote is. Her answer will likely be a: A. daughter cell B. cell that results from the fertilization of the ovum by a spermatozoa C. union of an egg by a sperm D. matured ovum
25. Which of the following will best describe mitosis? A. Fertilization of an ovum B. Cell division of the fertilized ovum C. Rupture of the ovum from the graafian follicle D. Implantation of the fertilized egg
26. Andrea discusses how the zygote enters the uterus which usually takes place in how many hours after fertilization? A. 180 hours B.72 hours
c. 48 hours d. 150 hours
27. The mulberry-like ball of cells that results from cleavage is called? A. Blastocyst B. Trophoblast
c. blastomore d. Morula
28. The zygote is normally implanted in what part of the uterus? A. Corpus B. Fundus
c. Cornea d. Cervix
Situation: Lisa, 19 year old single and pregnant for the first time is admitted to the labor room due to the passage of watery vaginal discharge, one hour PTA. I.E revealed 3 – 4 cms. Cervical dilation, 80% effaced, station 0 and (-) BOW.
29. What is the rationale for placing Lisa on complete bed rest upon admission? This will prevent: A. Infection B. Fatigue
c. fetal distress d. cord prolapse
30. Which of the following heartbeats per minute is indicative of fetal distress? A. 159 B. 121
c. 135 d. 165
31. What position is best for Lisa in order to prevent fetal hypoxia? A. left lateral B. dorsal recumbent
c. trendelenburg d. semi- fowlers
32. Which of the following best describes effacement? A. cervix becomes thinner B. presenting part has descended at the level of the ischial spine C. diameter of the presenting part of the fetus has passed through the pelvic inlet D. opening of the cervix becomes wider.
33. Station 0 means that the presenting part of the fetus is: A. still floating B. one centimeter above the ischial spine C. at the level of the ischial spine D. one cm below the ischial spine
Situation: Nurse Jane is assigned at the nursing unit at 6-2 shift.
34. She admitted girl Reyes, full term whose mother has a history of PROM. Jane anticipates that girl Reyes will b; A. Exposed to bili light B. Placed inside the incubator antibiotics
c. given I.V fluids d. given doses of
35. Boy Santoyas, 36 weeks AOG, has cryptorchidism, which refers to: A. undescended testes B. unretracted foreskin of the penis C. ventral location of the urinary meatus D. presence of fluid in the scrotal sac.
36. Girl Pablo develops jaundice. When does physiologic jaundice occur? A. after the 7th day birth B. upon birth
c. twenty four hours after d. between the 2nd and 5th day
37. Boy Malonzo demonstrated a tonic neck reflex, which is described as: A. fanning of the toes when a sharp object is pressed in the sole of his foot B. extension of his leg on the same side to which his head is turned C. turning of the head towards the side of the cheek that was touched. D. Grasping of any object placed in his hand
38. When the crib of girl Liboon is jarred, she develops sudden outward extension of her arms then slowly release. What reflex is this. A. Parachute B. Babinski
c. Landau d. Moro
39. What part of the mother will be the source of nourishment for the baby? A. Uterus c. Amniotic fluid B. Chorionic villi d. placenta
Situation: Janice a community health nurse is attending a home delivery a primigravida client.
40. A probable sign of pregnancy characterized by painless, irregular, abdominal; false labor contractions is called: A. Goodel’s sign c. Braxton Hicks contraction B. Leukorrhea d. Ballotment
41. I. E of 4 cm indicates: A. cervical canal is 4 cm in diameter B. the cervix is 4 cm thick C. the cervical external OS is 4 cm wide D. the cervical internal OS is 4 cm in diameter
42. The meaning of station +1 is: A. the level of ischial spine c. 1 cm below level of ischial spine B. 1 cm above level of ischial spine d. 1 cm above the pelvic inlet
43. It also known as the organ of menstruation. A. Ovaries B. uterus
c. Fallopian tube d. vagina
44. The average lifespan of ovum is: A. 12 hours B. 24 hours
c. 36 hours d. 48 hours
45. The process of implantation takes place in: A. uterus B. ovaries
c. ampulla d. tunica albuginea
46. The non pregnant uterus is lined by the: A. Endometrium c. deciduas vera B.Myometrium d. deciduas capsularis
47. Which terms refers to the externally visible structure of the female reproductive system extending from the symphysis pubis to the perineum? A. mons pubis B. vestible
c. vulva d. labia majora
Situation: Rowena is admitted at the ER with the following findings: Cervical dilation is 6 cm; fully effaced; cephalic presentation; 40 weeks AOG.
48. The nurse observes that Rowena’s abdomen has irregular scar lines as a result of stretching of the skin. This refers to; A. linea negra B. chloasma
c. striae gravidarum d. melasma
49. The obstetrician remarks that the fetus is dipping, which means that the fetus is; A. still floating B. reached the ischial spine C. in station +1 D. descending but has not reached the ischial spine
50. Rowena asks if she can take her meal. What should be the appropriate response of the nurse? A. “ your IV fluid is enough to give you nourishment.” B. “ you can take a light meal” C. “ no, the doctor orders you to be kept NPO” D. “ you cannot take food nor fluids because you are now in active labor.”
1.
b. c. d. e.
If a woman is pregnant for the second time, but her first pregnancy did not reach viability, what would be her parity using the four digit scoring system? 1 –0-0-1 0-0-1-0 0-1-0-00-1-0-1
Answer: B The formula for determining parity is TPAL T- term pregnancies = 38 weeks P- preterm =20-37 weeks A- abortion = pregnancy that do not reach viability 20-22 weeks L – number of living children
2. In providing health teaching for an expectant couple, what should the nurse tell them is a probable sign of pregnancy? c. d. e. f.
Fetal heart sound Positive pregnancy test Fetal movements felt by examiner Outline of fetus on sonogram
Answer: C Positive pregnancy test results are considered among the probable signs of pregnancy.
3. A woman in labor has a history of undiagnosed vaginal bleeding. Which procedure may be contraindicated on her arrival in the labor room? c. d. e. f.
Initiating an intravenous therapy Taking her blood pressure Examining her vaginal canal Monitoring FHR
Answer: C Examining her vaginal canal is contraindicated initially because of her pre admission history of bleeding. The problem may be placenta previa or other bleeding abnormalities in pregnancy.
4. A primipara at term has experience lightening. The nurse should anticipate which sign of discomfort that would normally accompany lightening? c. d. e. f.
Urinary frequency Dyspnea Heartburn constipation
Answer: A Lightening or descent of the fetus puts added pressure on the bladder, causing frequency.
5. A client is in active labor, the baby’s head is crowning, the client is bearing down, and delivery appears imminent. The nurse should: c.
d.
e.
f.
Transfer her immediately by stretcher to the delivery room. Tell her to breath through her mouth and not to bear down Instruct the client to pant during contractions and to breath through her mouth Support the perineum with the hand to prevent tearing and tell the client to pant.
Answer: D Gentle pressure is applied against the baby’s head as it emerges so it is not delivered too rapidly. The head is never held back, and it should be supported as it emerges to prevent a vaginal laceration.
1.
b. c. d. e.
The labor room nurse decides to intervene when the fetal heart rate pattern indicates: A baseline range of 110 to 160 bpm Absence of variability Early deceleration Mild variable deceleration
2. A primipara at term has experienced lightening. The nurse should anticipate which sign of discomfort that would normally accompany lightening. b. Urinary frequency c. Dyspnea d. Heartburn e. constipation
3. A newborn who weighed 7 lbs at birth now weighs 6 lbs 8 oz. Implementing health teaching, the nurse tells the mother the percentage of birth weight usually lost by normal, healthy babies. Which represents the maximum amount of normal weight loss for this newborn? b. 6 oz (170g) c. 8 oz (227g) d. 11 oz (317g) e. 16 0z (454g)
4. Of the following findings in full-term newborn, which is not an expected outcome of maternal hormone influence, and therefore should be reported? b. “witch milk” c. Slight vaginal bleeding d. Undescended testicles e. Linea negra
5. A woman who is a primipara at term is in active labor and is complaining of severe backache with contractions. Which of the following is not an effective comfort measure? b. Massage to the lower back between contractions c. External pressure to the sacrum during contractions d. Assistance with ambulation e. Position on side with pillows between legs.
Answer:1. b Sign of potential fetal distress. It can result from fetal hypoxia and acidosis and certain drugs that depress the central nervous system. A baseline range of 110-160 bpm is within normal limits
Answer 2. a Lightening or descent of the fetus puts added pressure on the bladder, causing frequency.
Answer 3 c. Term infants may lose 5%-10% of their birth weight
Answer 4 c. Undescended testicles is a condition unrelated to maternal hormonal influence. By 36 – 38 weeks of gestation, they should be descending through the inguinal canal and into the scrotal sac.
Answer 5 c. Ambulation would increase back discomfort by increasing fetal descent.
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