Maternity Nursing

External Structures Mons pubis – rounded fatty pad; pubic hair Labia majora – fatty fold of skin; covers labia minora Labia minora – with glands; rich nerve supply Clitoris – erectile tissue; abundant nerve endings Vestibule – space between the labia minora 1. urethral opening 2. Skene’s glands – secrets mucus 3. Bartholin’s glands – secretes mucus during arousal 4. vaginal orifice • Perineum – area between vaginal opening and anus • • • • •

Internal Structure • Fallopian tubes –

passageway of ova • Uterus  fundus  corpus  isthmus  cervix • Ovaries – almond shaped organs; ova and hormones • Vagina – birth canal

Pelvic Shapes Gynecoid

- wide and well rounded - female pelvis • Android  - narrow, heart shaped  - male pelvis • Anthropid - oval shaped • Platypelloid - wide but flat

Pelvic Divisions False Pelvis Above the pelvic brim True pelvis • below the pelvic brim • pelvic inlet, pelvic cavity and pelvic outlet • influence the progress of labor and delivery

Pelvic Measurements True conjugate- upper margin of symphysis pubis to sacral promontory; 11cm Diagonal conjugate – lower border of symphisis pubis to sacral promontory; 12.5 – 13cm Obstetric conjugate – most important measurement; inner surface of symphysis pubis to sacral promontory; 1.5 – 2cm less than diagonal conjugate Bi-ishial diameter – between the ischial tuberosities atleast 8cm

The Breasts Anterior chest wall

between the 2nd and 6th ribs • Glandular tissue, fat and connective tissue • Prolactin and oxytocin • Nipple and areola become darker in color during pregnancy

Breast profile: A - ducts B - lobules C -dilated section of duct to hold milk D -nipple E -fat F -pectoralis major muscle G -chest wall/rib cage Enlargement: A -normal duct cells B -basement membrane

Menarche • First menstration

• Onset of the menstrual cycle

• Normal range: 9 to 17 years old

Menstrual Cycle • Regularly recurring process that controls the

ripening and release of an ovum with the accompanying changes in the endometrium • Interaction of the pituitary gland, ovaries and

the uterus • Average length: 28 days

Menstrual Cycle: Hormones Follicle Stumulating Hormones (FSH) - growth and development of the ovum Luteinizing Hormone (LH) - ovulation Estrogen - proliferative phase of the menstrual cycle Progesterone - secretory phase of the menstrual cycle

Menstrual Cycle: Phase Menstruation: 1st day of the menstrual cycle; shedding of the endometrium Proliferative Phase: thickening of the endometrium; estrogen Secretory Phase: development of the endometrial glands and blood vessels; progesterone

Menopause Climacteric Decline ovarian function and hormone production Menstrual irregularity, vasomotor instability, loss of bone density

Female Sexual Response Excitement Phase – vaginal lubrication and congestion of genital blood vessels Plateau Phase – formation of orgasmic platform in the vagina Orgasmic Phase: strong rhythmic vaginal and uterine contractions Resolution Phase: return to previous condition

Fertilization Union of the sperm and ovum Occurs within 12 hours of ovulation and within 2-3 days of insemination Upper third of the Fallopian tube Sperm: XY chromosome Ovum: XX chromosome

Implantation Nidation 6-8days after fertilization Upper portion of the uterus Human Chorionic Gonadotropin (HCG) – from the trophoblast; basis of pregnancy test

Developmental Stages Zygote: fertilized ovum

Embryo: end of the second week to the end of the eight week

Fetus: end of the eighth week to term

Fetal Structures Fetal Membranes Hold the developing fetus and amniotic fluid Chorion – outer vascular membrane Amnion – inner membrane; forms the amniotic sac

Amniotic Fluid 500 to 1000 ml; alkaline Ph Functions: 1.Protects fetus 2.Allows fetal movements 3.Maintains fetal body temperature

Placenta Develops by the third month Exchange of nutrients and waste products beyween mother and fetus Immuneglobulin G (IgH) Hormones

Umbilical Cord Connects fetus and the placenta Length: 20 inches 2 arteries and 1 vein: umbilical arteries – deoxygenated blood Veins – oxygenated blood

Physiologic Changes During Pregnancy Reproductive System Increased vascularity of the genitalia Amenorrhea Increased vaginal secretion; changes in vaginal pH Softening and discoloration of the cervix Enlargement and change in uterine shape Braxton Hicks contractions Increase and breast size

Chadwick’s Sign: bluish discoloration of the vulva and vagina Goodell’s Sign: softening of the cervix Hegar’s Sign: softening of the uterine isthmus

Cardiovascular System Increased blood volume by 40-50% Greater tendency to coagulation Increase stroke volume and cardiac 0utput Increase heart size and heart rate Decreased blood pressure (second trimester) Sodium and water retention

Respiratory System Increase in oxygen consumption Increase respiratory volume Shortening of the thorax Increased vascularity of mucus membranes -> nasal And pharyngeal congestion Shortness of breath (last trimester)

Gastrointestinal System Increased HCG levels Alterations in taste and smell Increased salivation Heartburns Gum bleeding Decreased intestinal motility

Renal System Increased renal filtration rate Decreased renal threshold Water retention Decreased bladder capacity and bladder tone Frequency of urination

Endocrine System Increased basal metabolic rate (BMR) Increased body weight (1st trimester: 1-4 pounds; 2nd to 3rd trimester: 1 pound per week) Increased activity of the thyroid gland Decreased secretion of LH and FSH Oxytocin secretion during labor and delivery Progesterone secreted by corpus luteum until formation of placent

Musculoskeletal System Change in posture and walking gait Backache Increased joint mobility hypocalcemia

Integumentary System Increased skin pigmentation: a.Linea nigra – midline of the abdomen b.Chloasma – forehead, cheeks and nose c.Areola and nipples Stretch marks (striae) – abdomen, breast, thighs Decreased hair growth

Pscchological Changes During Pregnancy Ambivalance Acceptance Emotional Changes Body image Changes

Discomfort Associated with Pregnancy Nausea and Vomiting 1st trimester Increased HCG levels

Interventions: - Small, frequent, lowfats meals - Avoid fried foods - Avoid antiemetics during pregnancy

Heartburn 2nd and 3rd trimesters Displacement of the stomach, decreased intestinal motility and esophageal reflux

Interventions: - Small frequent meals - Avoid fatty and spicy food - Remain upright for 30 minutes after meals - Use antacid only as directed by physician

Fatigue 1st and 3rd trimesters Hormonal changes

Interventions: - Regular exercise - Frequent rest perionds - Avoid food and drinks containing stimulants

Varicose Veins 2nd and 3rd trimesters Venous congestion and weakening of the walls of the veins

Interventions: - Elevate feet when sitting - Avoid leg crossing - Avoid long periods of standing - Avoid constrictive clothing

Constipation 2nd and 3rd trimesters Decreased intestinal motility and displacement of the intestine

Interventions: - High fiber diet (fruits and vegetables) - Increase fluid intake - Regular exercise - Avoid laxatives

Backache 2nd and 3rd trimesters Increased lordosis due to enlarged uterus

Interventions: - Observe proper posture and body mechanics - Wear low heeled shoes - Firm mattress - exercise

Gravida Number of pregnancy regardless of the duration; includes present pregnancy Nulligravida: woman who has never been pregnant Primigravida: woman who is pregnant for the first time Multigravida: woman who is pregnant two or more times

Para Number of times a woman has given birth (beyond 2o weeks) regardless of outcome Nullipara: woman who has never given birth Primipara: woman who has given birth for the first time Multipara: woman who has given two or more times

Naegele’s Rule Used for estimating the expected date of confinement (EDC) Formula: subtract: 3 from the month of the LMP add: 7 to the first day of the LMP Example: LMP – April 2 4–3=1 2+7=9 EDC: January 9

Signs of Pregnancy Presumptive Sign Amenorrhea Nausea and vomiting Increased urinary frequency Enlargement of breasts Vaginal discoloration Quickening (16th -18th week)

Probable Signs Enlargement of the uterus Chadwick’s sign, Goodell’s sign and Hegar’s sign Braxton Hick’s contractions Ballotment Positive pregnancy test

Positive Signs Fetal heartbeat (Doppler: 10-12wks and fetoscope: 18-20 wks) Palpable active fetal movements Palpable fetal outline Demonstration of fetal outline (ultrasound: 6th wk or X ray: 12th wk)

Measurement of Fundal Height To evaluate gestational age 18-32 weeks: fundal height (in cm) = fetal age (in weeks) 16 weeks: fundal halfway between symphisis pubis and umbilicus 20-22 weeks: fundus at the umbilicus 36 weeks: fundus at the xiphoid process

Prenatal Care First visit: As soon as the woman suspects she is pregnant After first missed period Subsequent visits: 1 – 8 months: monthly 8th month: every 2 weeks 9th month: weekly

Maternal Risk Factors Infectious Disease German Measles (Rubella) - deafness, cataracts, cardiac defects Syphilis - spontaneous abortion, physical abnormalities, mental retardation Gonorrhea - neonatal conjunctivitis, pneumonia, sepsis HIV

Maternal Risk Factors Substance Abuse Smoking - LBW, prematurity, still birth, SIDS Alcohol - fetal death, FAS, IUGR, Marijuana - LBW, prematurity, tremors, sensitivity to light Cocaine - LBW, still birth, tremors, irritability, tachycardia

Pregnancy and Maternal Disease Cardiac Disoders congenital heart disease, rheumatic heart disease increased blood volume and increase cardiac output

Clinical presentation - Cough - Difficulty of breathing - Fatigue - Palpatations - Rales, murmurs - Tachycardia - edema

Diagnostics - Chest X ray - EKG - Echocardiography

Management - Digitalis - Diuretics - Antiarrhythmics - Anticoagulant - antibiotics

Nursing Consideration a. Prepartum - Provide adequate rest - Limit sodium intake - Limit weight gain to 15lbs - Avoid exposure to infections

b. During labor: - Monitor maternal VS and FHT - Administer oxygen and pain medication sa ordered - Side-lying or semi-Fowler’s position - Watch out for signs and symptoms of heart failure - Provide emotional support

c. Postpartum - monitor VS, I&O, weight, bleeding - Bed rest - Assist with ADL - Prevent infection

Diabetes Mellitus

more difficult to control during pregnancy changes in insulin requirement during pregnancy - First trimester: decrease - Second trimester: increase - Third trimester Infant of diabetic mother is at risk for hypoglycemia, RDS, congenital defects and stillbirth

gestational diabetes occurs in the 2nd or 3rd trimester factors predisposing to gestational DM: - Age (>35 years old) - Obesity - Multiple gestation - Family history screening: 26th week of pregnancy

Clinical Presentation - Polyuria - Polydypsia - Polyphagia - Weight loss - Frequent UTI - Large fetus

Diagnostics - Glucose challenge test - Oral glucose tolerance test - HbA1C

Glucose Challenge Test screening test (24-28 wks AOG) no need for preparation and fasting 50g glucose load normal: <140 mg/dl

OGTT confirmatory test 3 days high 100g glucose load 3 BG determination abnormal if: FBS - > 95 mg/dl 2 values > 145 mg/dl

Management 1.Diet 2.Exercise 3.Insulin

Nursing considerations - Instruct client regarding 1.Diet 2.BG monitoring 3.Complications - Monitor weight, signs of infection, preeclampsia - Assess fetal status - Assess insulin needs

Anemia hemoglobin <10 mg/dl or hematocrit <20% most common medical problem during pregnancy causes 1.Iron deficiency 2.Folic acid deficiency

Effects 1.Preterm birth 2.SGA 3.Increased risk of post partum infection and hemorrhage

Clinical presentation - Pallor - Fatigue - Dizziness - Shortness of breath - palpitations

Management - Iron supplement - Vitamin C - Folic acid supplement

Nursing considerations - Check hemoglobin and hematocrit levels every 2 weeks - Encourage intake of diet rich in iron and folic acid - Teach client regarding effects of iron ingestion - Assess the need for injectable iron

Tuberculosis droplet infection perinatal transmission is rare acquired by swallowing infected amniotic fluid

Clinical presentation 1.Mother 2.Neonate - lethargy, poor suck, failure to thrive, respiratory distress, hepatosplenomegaly

Diagnostics - mother: skin test (safe during pregnancy) chest X ray (abdominal shield) sputum examination - neonate:

skin test at birth and repeated at 3 – 4 months bacilli in gastric aspirate or placental tissue

Management - mother:

Multidrug therapy (INH, RIF, EMG) for 6-12 mos - neonate: INH for 3 mos (mother with active TB) BCG

Nursing considerations - Teach mother and family members regarding transmission and prevention - Promote breastfeeding only if the mother is noninfectious - Mother taking anti TB drugs may breastfeed the infant - During active disease, isolate and separate the infant from the mother

DIC consumption coagulopathy Increased clot formation in the circulation due to overstimulation of the clotting process

Predisposing factors - Abruptio placenta - Amniotic fluid - Embolism - Dead fetus - PIH - H mole - Hemorrhagic shock

Clinical presentation - Uncontrolled bleeding - Petechiae, purpura, ecchymoses - Hematuria - Hematamesis - shock

Diagnostics - Decreased platelet count - Prolonged PT and PTT - Prolonged clotting time

Fetal Diagnostic Tests Ultrasound uses: - Validation and dating of pregnancy - Assessment of fetal growth and viability - Measurement of fluid volume safe for fetus

Amniocentesis aspiration of amniotic fluid after the 14th week uses: - Identify chromosomal abnormalities - Determine fetal sex

Alpha-Fetoprotein Screening sample used: amniotic fluid done between 15 and 18 weeks uses: - To detect presence of neural tube defects and chromosomal abnormalities

Lecithin/Sphingomyelin Ratio (L/S Ratio) sample used: amniotic fluid use: to determine fetal lung maturity normal results at 35-36 weeks: 2:1 (low risk for developing respiratory distress syndrome)

Chorionic Villi Sampling use: to obtain tissue sample at implantation site fetal chromosomal, DNA or metabolic abnormalities transabdominal or transcervical earliest test possible on fetal cells between 9 – 12 weeks of gestation

Danger Signs of Pregnancy any form of vaginal bleeding sudden gush of fluid from the vagina presence of regular contractions before the expected date of confinement severe headache and visual disturbance facial edema intractable vomiting epigastric pain fever and chills

Complications of Pregnancy Abortion termination of pregnancy before the age of viability spontaneous or induced clinical presentation - Vaginal bleeding - Contractions - Passage of fetus/placental tissue

Type of Abortion Threatened – contractions/bleeding, cervix closed,

fetus not expelled Inevitable – cervix open, heavier bleeding Complete – all products of conception expelled Incomplete – membrane or placental tissue retained Missed – fetus dies in uterus but is not expelled Habitual – three consecutive pregnancies ending in spontaneous abortion

Nursing considerations - Maintain client on bed rest - IV fluids - Instruct client to keep all tissues passed - Prepare client for D & C or suction eveat

Incompetent Cervix • Pailess dilatation of the cervix in the absence of uterine contractions; due to cervical trauma • History of repeated abortions • Management - Cerclage - Shirodkar Technique/ McDonals Procedure

Nursing considerations - Bed rest - Monitor VS, fetal heart rate - Prepare for procedure - Monitor post-complications: 1.Rupture of membranes 2.Contractions 3.bleeding

Ectopic Pregnancy  Pregnancy outside the uterine cavity  Fallopian tubes – most frequent site; ruptures before the 12th week AOG  Clinical presentation - Bleeding - Hypotension - Abdominal pain and abnormal pelvic mass - Decreased hemoglobin and hematocrit; leucocytosis

Management - surgery: salpingostomy; salpingectomy - Blood transfusion Nursing considerations - Obtain vital signs - Monitor bleeding - Prepare patient for surgery - Allow client to express feelings about loss of

pregnancy

Hyperemesis Gravidarum Intractable nausea and vomiting that last beyod the first trimester Most pronounced upon waking up Clinical presentation - Persistent nausea and vomiting - Dehydration - Electrolyte imbalance - Weight loss

Nursing considerations - Monitor vital signs, fetal heart rate and fetal -

activity Monitor I&O, electrolytes and hematocrit Small feedings Dry diet, alternate liquids and solids Weight patient daily Assess fetal growth

Hydatidiform mole  Developmental anomaly of placenta  Grape-like clusters  Common in women over 40  Clinical presentation - Increasing size of uterus - Increased levels of HCG - Vaginal bleeding - Absent fetal heart sounds - Ultrasound: snowstorm pattern

Management - Evacuation of the uterus (suction curretage) - Hysterectomy - chemothearapy Nursing considerations - Instruct patient to monitor HCG levels for 1 year - Teach patient how to use contraceptives to delay

pregnancy by at least a year

Prenancy-Induced Hypertension Vasopastic hypertesion, edema and proteinuria Onset: after 20th week of pregnancy Classification: 1.Preecclampsia (mild or severe) 2.Eclampsia Management: termination of pregnancy Complication: HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)

Mild Preeclampsia Onset: between 20th and 24th week of pregnancy Hypertension of 15-30 mmHg above the baseline Sudden weight gain (1 lb/wk), edema of the hands and face, (+1) protenuria Nursing considerations: - Bed rest in left position - Monitor blood pressure, weight, deep tendon reflexes - Increase dietary carbohydrate and protein

Severe Preeclampsia Blood pressure of 150/100 – 160/110 Headache, epigastric pain, nausea and vomiting, visual disturbance (+4) protenuria, oliguria, hyperreflexia Management: magnesium SO4, hydralazine Nursing considerations: - Daily funduscopic examinations; monitor reflexes - Seizure precautions - Continue to monitor 24 -48 hours post partum

Eclampsia C0nvulsions, coma, cyanosis, fetal distress Bp > 160/110, severe edema, 4+ proteinuria Nursing considerations: - Administer oxyden - Minimize all stimuli - Seizure precautions - Monitor vital signs - Prepare for C section

Placenta Previa Abnormal implantation of the placenta in the lower uterine segment Classification 1.Complete (total, central) 2.Partial 3.Marginal (low lying)

Clinical presentation - Painless vaginal bleeding (third trimester) - Abnormal fetal position - anemia Management - Based on maternal and fetal condition 1.Conservative 2.Cesarian section

Nursing considerations - Bed rest - IV fluids - Blood transfusion as needed - Monitor vital signs, FHR, fetal activity - Avoid vaginal examinations - Prepare for ultrasound - Prepare for cesarian section

Abrputio Placenta Premature separation of a normally implanted placenta Risk factors - Maternal hypertension - Short umbilical cord - Abdominal trauma - Smoking/use of cocaine

Clinical presentation - Vaginal bleeding - Abdominal and low back pain - Frequent contractions - Uterine tenderness - Hypotension, tachycardia, pallor - Concealed hemorrhage: abdominal rigidity,

increase in fundal height

Management - Cesarian section - Blood transfusion - IV fluids - O2 inhalation Nursing consideration - Relieve pressure on the cord - Elevation of the presenting part - Oxygen at 8 – 10 LPM via face mask - Cesarian section

Prolapsed Cord Protusion of the umbilical cord into the vagina Risk factors - Ruptured membranes - Small fetus - Breech presentation - Transverse lie - Excessive amniotic fluid

Clinical presentation - Visible cord at the vaginal opening - Palpable cork on vaginal examination - Fetal bradycardia Management - Relieve pressure on the cord - Elevation of the presenting part - Oxygen at 8-10 LPM via face mask - Cesarian section

Nursing considerations - knee-chest or Trendelenberg position - Monitor fetal heart tones - Avoid palpatation or handling of the cork - Prepare client for surgery - Allay client’s anxiety

Uterine Rupture Tear in the uterine wall Most serious

complication of labor Risk factors 1.Previous cesarian section 2.Mulitiparity 3.Intense uterine contractions

Clinical presentation 1.Complete rupture - sudden, severe -

abdominal pain Abdominal rigidity Cessation of contractions Absence of FHR Shock

2. Incomplete rupture - Abdominal pain with contractions - Slight vaginal bleeding - Failure of cervical dilatation - Absence of FHR

Management - Surgery (c section, hysterotomy, hysteretomy) - Blood trasfusion as needed Nursing consideration - Monitor maternal vital signs and FHR - Watch out for signs and symptoms of shock - Prepare client for surgery - Provide emtional support for the client

Labor – coordinated sequence of uterine contractions resulting in cervical effacement and dilation followed by expulsion of the products conception Effacement – shortening and thinning of the cervix Lightening – descent of the fetus into the pelvic inlet 2 weeks prior to onset of labor

Lie – relationship of the long axis of the fetus to the long axis of the mother Presentation – part of the fetus that first enters the mother’s pelvis Position – relationship of the presenting part to the maternal pelvis Station – measurement of the descent of the presenting part into the maternal pelvis

True Labor Near term Increasing frequency, duration and intensity Pain begins in the back, radiates to the abdomen Progressive fetal descent and cervical dilation “bloody show”

False Labor Early in pregnancy Irregular; non progressing Discomfort in the abdomen and groin No fetal descent and

cervical dilation No “bloody show”

Stages of Labor First Stage (Dilation) 1.Latent phase (0-4cm) 2.Active phase (4-8cm) 3.Transition (8-10cm) Nursing considerations - Monitor maternal and fetal VS - Monitor progress of labor - Teach breathing techniques - Discourage pushing until cervix is dilated

Second Stage (Expulsion) Full cervical dilation to fetal expulsion Nursing considerations - Perform assessment every 5 minutes - Monitor maternal vital signs - Monitor FHR before, during and after contractions - Prepare for delivery - Maintain privacy - Catheterize if bladder is distended

APGAR Scoring Performed at 1 and 5

Score interpretation

minutes - 7-10: no need for Parameters: - Heart rate - Respiratory rate - Muscle tone - Reflex irritability - color

resuscitation - 3-6: requires resuscitation - 0-2: needs immediate critical care

Third Stage (Placental) Placental separation and expulsion 5-10 minutes after delivery of the baby Signs of placental separation: - Sudden gush of blood - Lengthening of the cord - Change in uterine shape Schultze’s mechanism Duncan’s mechanism

Nursing considerations - Assess maternal vital signs - Assess uterine status - Check completeness of the placenta - Inspect perineum - Promote bonding

Fourth Stage (Recovery) 1-4 hours after delivery Nursing considerations - Check vital signs - Palpate fundus for firmness - Monitor color and amount of lochia - Inspect perineum; apply ice packs

Duration of Labor Primipara Stage 1:

Multipara 12 – 13

hours Stage 2: 1 hour Stage 3: 3 – 4 minutes Stage 4: 1 -2 hours

Stage 1: 8 hours Stage 2: 20 minutes Stage 3: 4 – 5

minutes Stage 4: 1 – 2 hours

Induction of Labor Deliberate stimulation of uterine contraction prior to

labor

1.Medical - Oxytocin (pitocin) - Methergine - Prostaglandin 2.Amniotomy - Deliberate rupture of membranes

Nursing considerations Continuous fetal monitoring Monitor: maternal BP, PR and progress of labor Discontinue oxytocin infussion if 1.There is fetal distress 2.Hypertonic contractions develop 3.Signs of complications are present (hemorrhage,

shock, abruptio placenta, amniotic fluid embolism) Inform physician

Obstetric Analgesia Goal: to relieve pain and discomfort of labor

and delivery with the least effect on fetus Routes: 1.Inhalation (methoxyflurane, nitrous oxide) 2.IV (sodium pentothal) 3.Regional (lidocaine, tetracanine, bupivacaine

- Lumbar epidural, caudal, subarachnoid

Nursing considerations Monitor maternal/fetal vital signs Monitor progress of labor Check for allergies Record drug used, time, amount, route, site, client site Empty patient’s bladder Position client appropriatel

Dystocia Difficult or prolonged labor Problem in any of the following 1.Passenger 2.Passage way 3.Powers 4.Placenta 5.Psychological response of the mother

Signs of fetal distress Slowing down of the fetal heart rate Meconium-stained amniotic fluid Nursing intervention Monitor FHR Place patient on left side Prepare for emergency delivery Provide emotional support

Electronic Fetal Monitoring Purpose: evaluate fetal condition and

tolerance of labor external/internal Heart rate

Pattern of Fetal Heart Rate Deceleration 1.Early deceleration 2.Late deceleration 3.Variable deceleration

Early deceleration Deceleration begins early in contraction Fall in heart rate stays within the normal range Heart rate returns to baseline Due to compression of fetal head against the

cervix Not a dangerous pattern No intervention needed

Late Deceleration Deceleration start late in contraction Fall in heart rate > 20 bpm Heart rate does not return to baseline Due to uteroplacental insufficiency Dangerous pattern Change maternal position, administer O2,

discontinue oxytocin, prepare for immediate delivery if pattern is consistent

Variable Deceleration Onset not related to contractions Abrupt and dramatic swings in heart rate;

rapid return to baseline Due to compression of the umbilical cord Not a dangerous pattern Change maternal position, administer O2, discontinue oxytocin infusion If persistent, CS will be needed

Obstetrical Procedure Episiotomy Incision made into

the perineum to enlarge the opening Prevents perineal laceration Types: 1.Midline (median) 2.Mediolateral

Nursing considerations - Apply ice packs for the 24 hours - Hot sitz bath to promote healing - Check for signs of bleeding/infection - Instruct client about perineal hygiene

Forcep Delivery Indication: to

-

shorten second stage of labor Fetal distress Poor maternal effort Medical condition Maternal fatigue Large infant

Nursing -

considerations Explain procedure Reassure patient Monitor mother and fetus continuously After delivery, check mother and fetus for injuries

Vacuum Extraction Used to assist delivery of the fetal head Suction device applied to fetal head and

traction applied during contractions Nursing considerations - Do not keep suction device longer than 25 minutes - Continuous fetal monitoring - Assess infant fro cerebral trauma

Cesarian Section Delivery of the fetus through an abdominal and

uterine incision Indications: - Fetal distress - Abnormal presentation (breech, face, shoulder) - CPD - Placental abnormalities - Multiple gestation - Previous CS - Arrest in labor

Nursing considerations - Obtain inform consent - Explain procedure to the mother - Monitor mother and fetus continuously - Prep abdomen and pubic area - Insert IV and catheter - Pain relief - Encourage turning, coughing and deep breathing - Monitor for signs of bleeding and infection

Physiologic Changes Involution of the Uterus Return of the uterus to its nonpregnant size - 1 hour postpartum: fundus at the level of the

umbilicus - Fundus decrease by 1cm per day - Fundus no longer palpable by the 10th day

Lochia 1.Lochia rubra – red; 1-3 days 2.Lochia serosa – pinkish-brown; 4-10 days 3.Lochia alba – yelowish-white; 11-21 days Foul smelling lochia indicates infection Menstrual flow resumes within 8 weeks in

nonbreastfeeding mothers, within 3-4 months in breastfeeding mothers.

Normal blood loss: 500cc (vaginal delivery); 1 L

(CS) Increased WBC count (up to 20,000) Fever may be present Colostrum secreted from 1-3 days Hemorrhoids are common

Postpartum Discomfort Intervention Perineal discomfort Episiotomy Breast engorgement

Postparutum blues

Ice packs (1st 24 hrs) warm sitz bath (after 24hrs) Analgesics spray perineal care after voiding Analgesics breastfeed frequently Ice packs between feedings warm soaks before feedings Encourage verbalization

Cracked nipples

Air dry nipples 1-20 minutes after feeding rotate baby’s position after feeding Make sure baby is latched on the areola Do not use soap when cleaning the breast

Phase of Maternal Adjustmet 1. “Taking In” - 1-2 days post partum - Predominance of mother’s needs (sleep and

food) - Help with daily activities as well as child care - Listen to the mother’s experience during labor and delivery - Not the best time to do teaching about care of the neonate

2. “Taking Hold” - 3-10 days post partum - Mother starts assuming the care of the -

neonate Emotional lability may be present Best time to teach about baby care Reassure the mother that she can perform the tasks of being a mother

3. “Letting Go” -

Fifth or sixth week postpartum New baby is included in new lifestyle Focus on entire family Mother may be overwhelmed by demands on her time and energy

Postpartum Complications Postpartum Hemorrhage Loss of more than 500 ml of blood Causes: - Uterine atony - Lacerations - Retained placental fragments

Nursing considerations - Monitor vitals signs - Monitor fundus - IV fluids - Administer medications - Measure I and O - Keep client warm

Postpartum Infection Occurs within 10 days after birth Predisposing factors; - Prolonged rupture of membranes - Cesarean section - Trauma - Maternal anemia - Retained placental fragments

Clinical presentation - Fever (100.4 F or 37.8 C) for 2 consecutive -

days Chills Abdominal or pelvic pain Foul-smelling vaginal discharge Dysuria Increased wbc count

Management - Antibiotics - Warm sitz bath Nursing considerations: - semi-Fowler’s or high Fowler’s position - High-calorie, high protein diet - Increase oral fluids (>3 L/day)

Mastitis Infection of the breast Usually bilateral Staphylococcus aureus Clinical presentation - Redness and tenderness - Fever and chills - malaise Breast abscess

Management - Antibiotics - ice Nursing considerations - Teach importance of hand washing - Empty breast regularly - Mother may continue breastfeeding

Labor Maternal Weight Gain - Underweight woman: 28-40 lbs - Normal weight woman: 25-35 lbs - Overweight woman: 15-25 lbs - Obese woman: less than: 15 lbs

Labor Maternal weight gain distribution - fetus, placenta, amniotic fluid = 11 lbs - Uterus = 2 lbs - Increase blood volume = 4 lbs - Breast tissue = 3 lbs - Maternal stores = 5-10 lbs

Labor Umbilical cord - One large vein - Two smaller vein - Made of Whaton’s Jelly - Fetal Circulation

> ductus venosus > Ductus arteriosus > Foramen ovale

Labor Adequacy of the maternal environment - Nutrition - Hyperthermia - Chronic disease, diabetes, thyroid, cardiac, and

circulatory - Substance abuse - TORCH (T=toxoplasmosis, O=other; gonorrhea, syphilis, varicella, hep B, group B strep. HIV, R=rubella, C=cytomegalovirus, H=herpes

Labor Stages of Labor - First Stage Dilating - Second Stage – Epulsion - Third Stage – Placental - Fourth Stage – Post Partum

Labor First Stage - Beginning gots short, mild, lasting 10-15

minutes apart, mild discomfort - Progressively got longer, stronger, lasting 6090 seconds, ends woth complete dilatation - Latent=0.3cm, 3hrs primip, 2 hrs multip. - Transition=8-10cm, loss of control, urge to push

labor Second Stage - Complete dilatation of the cervix - 50 minutes for a primip, 20 minutes for multip - Pushing - Crowning - Ends with delivery of baby

Labor Third Stage - Begins after delivery of baby and terminates

with the birth of the placenta - Signs of Placental Separation - globular and firmer uterus - rise of uterus in abdomen - descend of umbilical cord - sudden gush of blood - Placental expulsion

Labor Fouth Stage - First hour post partum - Restoration of physiological stability - Assessments • Vital signs • Fundus checks • Amount lochia • Perineum • Bladder function or distention • Family education- handling/breastfeeding

Labor Position changes of -

the fetus Descent Flexion Internal rotation Extension External rotation Expulsion

Labor Fetal Presentation - L.O.A. – Left -

occipitoanterior L.O.T. – Left occipitotransverse L.O.P. – Left occipitoposterior R.O.T. – Right occipitoanterior R.O.T. – Right occipitotransverse R.O.P. – Right occipitoposterior

Delivery Fetal position-Assessment - Five ways 1.Abdominal palpation 2.Vaginal examination 3.Combined auscultation and examination 4.Ultrasound 5.X-ray

Delivery Abdominal Palpation - Leopoid Maneuver 1.Palpate the upper abdomen to determine contents

of fundus 2.Locate the fetal back in relation to the right and left sides 3.Locate the presenting part at the inlet and check for engagement by evaluating mobility 4.Palpate just above the inguinal ligament on either side to determine the relationship of the presenting part to the pelvis

Delivery Perineum - Episiotomy  lateral

medbilateral  median 

Postpartum Breastfeeding Teaching Safety Family planning siblings

Post Partum Lochia - Rubra - Serosa - Alba