Ncm 101

NCM 101 Reproductive Health Definition of terms: HEALTH – state of physical, mental, social well – being and not merely the absence of disease or infirmity. REPRODUCTIVE HEALTH – addresses the reproductive processes, functions and system at all stages of life. REPRODUCTION – biological process where a new individual is produced. PHILIPPINE REPRODUCTIVE HEALTH (Cairo, Egypt – 1994) - Established by the AO 1-As.1998 by DOH - AO 43, s.1999 o Was issued adopting reproductive health policy to integrate reproductive health services in all health facilities as part of basic package of health services and thus ensuring more efficient and effective referral system from primary to tertiary, public and private facilities. Main Objectives: 1. Reducing maternal mortality rate. 2. Reducing child mortality. 3. Halting and reserving spread of HIV and AIDS *HIV – blood transfusion, trans – placental, sexual intercourse. - Abstinence - Be faithful - Condom - Drug avoidance - Education campaign - F*** yourself 4. Increasing access to reproductive health information and services. TEN ELEMENTS OF REPRODUCTIVE HEALTH 1. Family planning. 2. Prevention and management of reproductive tract infections (RIH) including STI’s and HIV/AIDS. *Benzathine penicillin 3. Maternal and child health nutrition (MSC & N). 4. Adolescent reproductive health (ARH). 5. Prevention and management of abortion and its complications (PMAC). 6. Education and counseling on sexuality and sexual health, men’s reproductive health (MRH) and involvement. 7. Prevention and management of breast and reproductive tract cancers and other gynecological conditions. 8. Violence against women and children (VAW). 9. Prevention and management of infertility and sexual dysfunction. THE MENSTRUAL CYLCE / FEMLE REPRODUCTIVE CYCLE A. Purpose: to bring an ovum to maturity and renew a uterine tissue bed that will be responsible for its growth should it be fertilized. B. Definition of Terms: CLIMACTERIC – period of a woman’s life when she is passing from a reproductive to a non – reproductive state, with regression of ovarian function. MENSTRUATION – periodic vaginal discharge of bloody fluid from non – pregnant uterus that occurs from the age of puberty to menopause.

MENSTRUAL CYCLE – a complex interplay of events that occurs simultaneously in the uterus, hypothalamus and pituitary glands and the ovaries that results in ovarian and uterine preparation for pregnancy. MENOPAUSE – cessation of menstrual cycle. OVULATION – periodic ripening the discharge of ovum from the ovary, usually 14 days before the menstrual flow. MITTELSCHEMERZ – localized lower abdominal pain that coincides with ovulation. SPINNBARKEIT – property of the cervical mucous to stretch a distance before breaking. FERNING – a ferning pattern of cervical mucus occurs with high estrogen levels. C. Characteristics of a Normal Menstrual Cycle MENARCHE Onset: 11 – 13 years old Range: 9 – 17 years old INTERVAL Average: 28 days Unusual: 23 – 35 days DURATION Average: 2 – 7 days Range: 1 – 9 days AMOUNT 30 – 80 mL / menstrual period Saturating pad / tampon in less than an hour is heavy bleeding. COLOR Dark red; blood mucus, endometrial cells. ODOR Similar to that of marigolds. D. Physiology of Menstrual Cycle 1. Hypothalamus a. Factors affecting GnRH release i. Estrogen ii. Progesterone iii. Prolactin iv. FSH v. LH b. Release GnRH (LNRH) which initiates menstrual cycle. c. Sensitive to estrogen produce by adrenal glands during childhood. d. Becomes less sensitive to estrogen feedback beginning puberty. 2. Pituitary Gland a. Produces 2 hormones that influence the menstrual cycle. b. FSH, active early in the cycle and responsible for the maturation of the ovum. c. LH, most active hormone at the midpoint of the cycle, responsible for ovulation and growth of the uterine lining during the second half of the menstrual cycle. *Adenohypophysis – anterior pituitary gland 3. Ovary a. FSH and LH cause growth in the gonads. b. Ovarian cycle occurs. i. Ovarian Cycle 1. Follicular Phase • Period during which an ovum matures. • FSH and LH levels rise slightly. • Primordial follicle produces a clear fluid (follicular fluid), high in estrogen (estradiol) and some progesterone (Graafian follicle). 2. Ovulatory Phase • Marks the beginning of the luteal phase and occurs about 14 days before the next menstrual period.

3. Luteal Phase • LH acts on the old follicle causing it to produce a bright yellow fluid (Lutein), high in progesterone and some estrogen (corpus luteum). 4. Uterus a. Menstrual cycle occurs. i. Menstrual Cycle 1. Proliferative Phase • Estrogenic, Follicular, Post – menstrual Phase • Day 5 – 14 • The endometrium proliferates approximately eightfold 2. Secretory Phase • Progestational, Luteal, Premenstrual Phase • Blood vessels and endometrium become corkscrew or twisted in appearance and dilated with quantities of glycogen, proteins, lipids and minerals. 3. Ischemic Phase • The blood supply to the functional endometrium is blocked and necrosis develops. • The functional layer separates from the basal layer and menstrual bleeding begins making day 1 of next cycle. 4. Menstrual Phase • Shedding of the functional 2/3 of the endometrium. • The basal layer is always retained. • Regeneration begins near the end of the cycle from cells derived from the remnants in the base. DEVELOPMENTAL STAGES A. Ante - partal - A term used to describe the period before labor or birth. 1. FETAL DEVELOPMENT a. Fertilization (zygote) • Also referred to as conception, impregnation, fecundation. • The union of an ovum and spermatozoa which usually occurs in the outer third layer of fallopian tube (ampulla). • “The Beginning of Pregnancy” • Ovum: Life – 24 – 48 hours Zona Pellucida – a ring of muco polysaccharide fluid. Corona Radiata – a circle of cells. • Spermatozoon: Life – 48 – 72 hours Capacitation – final process that a sperm must undergo to be ready for fertilization. Hyaluronidase – proteolytic enzyme produced by the sperm to… Semen – 2.5 mL (50 – 200 million / mL) Average of 400 million/mL/ejaculation b. Implantation (embryo) • Contact between the growing structure and the uterine endometrium. • Occurs approximately 8 – 10 days after fertilization at the upper part of the uterus. • It takes 3 – 4 days for the zygote to journey to the uterus where mitotic cell division happens. • Floats in the uterus for 3 – 4 days.

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MORULA: because of the outward – bumpy appearance o “Morus” mulberry; 15 – 50 cells • BLASTOCYST: one which will attach to the uterine wall. o Trophoblast – outer layer that will form the placenta and membrane. o Embryoblast – forms the embryo. • Implantation Bleeding – mistaken as menstrual period. - 4 weeks late calculation of pregnancy. c. Stages of Fetal Development i. Fertilized Ovum • From conception through first 2 weeks of pregnancy. • Nidation complete by the end of this period. • Embryo: 2nd – 8th week (critical time for development). • Fetus: end of the 8th week to termination of pregnancy. • Organ systems develop from 3 primary germ layers. a. Ectoderm – brain and spinal cord, peripheral nervous system, pituitary gland, sensory epithelium of the eye, ear, and nose, epidermis, hair nails, subcutaneous glands, mammary glands and tooth enamel. b. Mesoderm – cartilage, bone, connective tissue, muscle tissue, heart, blood vessels, blood cells, lymphatic system, spleen, kidneys, adrenal cortex, reproductive system and lining membranes (pericardial, pleural, peritoneal). c. Endoderm – lining of GIT, RT, urinary bladder, urethra and ear canal, tonsils, thyroid, parathyroid, thymus, liver, and pancreas. ii. Measurements of Length of Pregnancy • Days: 267 – 280 • Weeks: 40, plus or minus 2 • Months: lunar (10); calendar (9) • Trimester: 3 iii. Expected date of Delivery (EDC/EDD) • Nagele’s Rule – most common method in computing EDD. a. Add 7 days to the first day of the last normal menstrual period. b. Subtract 3 months. c. Add 1 year. • McDonald’s Rule a. fundic height (cm) x 2/7 = AOG in lunar months. b. Fundic height (cm) x 8/7 = AOG in weeks. • Bartholomew’s Rule a. 12 weeks – level of umbilicus b. 16 weeks – halfway between umbilicus and symphysis pubis. c. 20 weeks – level of umbilicus. d. 24 weeks – 2 fingers above the umbilicus e. 28 – 30 weeks – halfway between umbilicus and xyphoid process. f. 40 weeks – at 34 weeks due to lightening. iv. Time Table Development All systems in rudimentary form; heart chambers formed and is beating. L= 0.4 – 0.5 cm long; Wt. = 0.4 g

8 weeks 12 weeks 16 weeks 20 weeks 24 weeks 28 weeks 32 weeks 36 weeks 40 weeks

Some distinct features in face, head large in proportion to rest of body, some movement. L = 2.5 cm; Wt. = 0.4 g Sex distinguishable; ossifications in most bones, kidneys secrete urine, able to such and swallow. More human appearance; earliest movement likely to be felt by mother. L = 11.5 – 13.5 cm; Wt. = 100 g. Vernix caseosa and lanugos appear heart rate audible, bones hardening. L = 16 – 18.5 cm; Wt = 3oo g. Body well proportioned; skin red and wrinkled, hearing established. Infant viable, but immature if born at this time, body less wrinkled, appearance of nails. L = 27 cm; Wt = 1100 g. Subcutaneous fat beginning to deposit, L/S ration in lungs now 1.2:1, skin smooth and pink. Lanugos disappearing; L/S ratio 2:1 L = 35 cm; Wt = 2200 – 2900g Full term pregnancy. Baby is active, with good muscle tone; strong suck reflex, little lanugos. L = 40 cm; Wt = 3200 g or more. d. Products of Conception i. Fetus ii. Membranes (bag of waters) – 2 fetal membranes composed of the amnion (inner membrane) and the chorion (outer membrane). iii. Amniotic Fluid – clear, yellowish, fluid surrounding the developing fetus. • Derived from fetal urine and fluid transported from the maternal blood across the amnion. • Increases until 500 – 1500 mL at term • Protects fetus and promote normal prenatal development. • Allows free movement. • Maintains temperature. • Provides oral fluid. • *Volume is important factor in assessing fetal well – being. a. Oligohydramnios – abnormal small quantity of fluid which is less than 500 mL. 1. associated with poor fetal lung development malformations that results from compression of fetal parts. 2. may occur because the kidneys fail to develop, urine excretion is blocked, or placental blood flow is inadequate. b. Hydramnios (Polyhydramnios) – more than 2000 mL of amniotic fluid.  May occur when the fetus has a sever malformation of the CNS or GIT that prevents normal ingestion of amniotic fluid. iv. Placenta – is a thick, disk shaped organ composed of 15 – 20 cotyledons (maximum of 30). • Fetal side, smooth with branching vessels covering the membrane – covered surface. • Maternal side, rough where it attaches to the uterus.

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Major functions include; metabolic, transfer of substances between mother and fetus, endocrine. • Presentation: Duncan (dirty) or Schultz/e (shiny). • Hormones produce by the placenta: a. Human Chorionic Gonadotropin (HCG) – ensures a continued supply of estrogen and progesterone needed to maintain the pregnancy.  Basis of pregnancy test. b. Chorionic Somatomammotropin or Human Placental Lactogen – similar to a growth hormone and stimulates maternal metabolism to supply needed nutrients for fetal growth.  Prepares breasts for lactation. c. Progesterone – maintains the endometrium  Decreases the contractility of the uterus.  Stimulates development of breast alveoli and maternal metabolism. d. Estrogen – stimulates uterine growth and utero placental blood flow. v. Umbilical Cord • Lifeline between fetus and placenta. • Contains 2 arteries and 1 vein (AVA) • Cushioned by a soft substance called WHARTON’s jelly to prevent obstruction due to pressure. • No pain receptors in the umbilical cord. • At term: 2 cm in diameter; 30 – 90 cm in length. e. Fetal Circulation i. 2 arteries – carry deoxygenated blood. ii. 1 vein – carry oxygenated blood iii. Ductus Venosus – connects umbilical vein and inferior vena cava, largely bypassing liver and closes after birth. iv. Foramen Ovale – allows blood flow from right atrium to left atrium, bypassing lungs and closes immediately after birth. v. Ductus Arteriosus – allows blood flow from pulmonary artery to aorta, bypassing fetal lungs. vi. Diagram of Fetal Circulation 2. MATERNAL CHANGES DURING PREGNANCY  Psychological Changes of Mother o 1st Trimester – accepting pregnancy. o 2nd Trimester – accepting the baby. o 3rd Trimester – preparation for parenthood.  Couvades’ Syndrome – father experiences fatigue, nausea, vomiting, back pain.  Pregnancy is a period for: o The needs of the fetus. o Meeting the stress of pregnancy and labor.  Changes during pregnancy can be: o Metabolic – chemical o Physiological – function o Anatomical – physical  Reproductive System • Uterus – increases from 60 gm to 1000gm

Hypertrophy of myometrial cells growing fetus. o 1/6 of maternal blood volume is contained in uterus at the end of the pregnancy. o Braxton Hick’s contraction – painless intermittent contractions. o Uterine position over time – weeks. • Cervix – mucous plug; seals cervix o Goodell’s sign: softening the cervix o Chadwick’s sign: bluish discoloration of the cervix, vagina, and labia. o Hegar’s sign: softening of the lower uterine segment. • Breasts – enlarged and more nodular o Nipples are erectile. o Areolas darken o Colostrums – last trimester Respiratory System • Increase in O2 consumption and volume of air. • Diaphragm is pushed upward; breathing changes from abdominal to chest. Cardiovascular System • Blood volume increases to 45 % above nonpregnant level. • Cardiac output increase. • Pulse increases by 10 – 15. • Dependent edema and venous stasis. • Delusional/pseudo anemia • Supine Hypotensive Syndrome – compression of the vena cava causing blood pressure to fall • As long as a woman has started having menstrual cycle, she has to take iron supplements because she’s at risk of pregnancy. • Supine Hypotensive Syndrome – when woman lies on her back, circulation to the placenta may also be reduced by increased pressure on the woman’s aorta. o Signs and Symptoms  Faintness  Lightheadedness  Dizziness  Agitation o Nursing interventions  Turning to left side  If the woman must remain flat for any reason, a small towel roll placed under one hip will also help to prevent supine hypotensive syndrome (right side). Urinary System • Glomerular filtration rises by 50 % due to increase cardiac output. • Glycosuria – excretion of glucose in the urine. o

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Frequency during and third trimester due to pressure on bladder. • The diameter of the uterus and the bladder capacity increase causing stasis. • Susceptible to UTI. • Gestational DM – glycosuria. Gastrointestinal • Morning sickness – occurs due to elevated levels of estrogen and progesterone. • *Cardiac sphincter is relaxed due to high levels of progesterone; mother is more prone to GERD (Gastro-esophageal Reflux Disease). • What can you do about morning sickness? o Eat crackers, toast or dry cereal. o Eat small, frequent meals (there is tie for digestion and absorption.) o Limit fried, fatty and spicy foods (triggers production of HCL). o Drink liquids in between meals. o Have a snack before bed. o Sleep in a well ventilated room. Musculoskeletal System • Joints of pelvis relax due to hormone – relaxin. • Waddling gait • Center of gravity changes • Diastasis recti – separation of rectus abdominis muscle. • Lordosis is common due to the change of the body’s center of gravity; PRIDE OF PREGNANCY. Integumentary • Chloasma – increases pigmentation over bridge of nose and cheeks; THE MASK OF PREGNANCY. • Linea Nigra – mark vertical line that appears on the abdomen during the pregnancy. • Linea Alba – white line • Striae Gravidarum – stretch marks Weight Gain • Normal Range o Pre – pregnant BMI – 25 – 35 pounds (30 is ideal) o Baby – 8 pounds o Placenta – 2 – 3 pounds • Overweight: 28 – 40 pounds • Underweight – 15 – 25 pounds

3. Diagnosis of Pregnancy • Presumptive Signs (Subjective) o NASALO Q B Sperm?  Nausea and vomiting  Amenorrhea • Primary amenorrhea – congenital anomaly; absence of uterus or failure of the ovary to receive or maintain egg cells.

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Secondary Amenorrhea – cessation of menstrual cycle; menopausal stage; normal cycle: 28 days; > 3 months without cycle = secondary amenorrhea. • Oligoamenorrhea – beyond 35 days without cycle.  Skin discoloration • Chloasma or melasma • Melanin stimulating hormone – increased due to increased progesterone and estrogen.  Abdominal changes • There is uterine enlargement • Linea nigra – below the xyphoid process to symphysis pubis. • Striae Gravidarum – Lines of Pregnancy  Laging pagod (fatigue)  Overactive bladder (frequent urination)  Quickening – first movement felt by the mother  Breast changes – darkening of areola; nipple is more erectile. • Probable Signs o Noted by the health care provider but are still not conclusive for pregnancy. o CGURO…Pregy B U?  Chadwick’s sign – bluish purplish discoloration of the vagina  Goodell’s sign – softening of the cervix  Uterine softening (Hegar’s sign) – lower part of the uterus.  Rising and rebound of fetus when tapped (Ballottement).  Outline of the fetus felt through palpitation.  Braxton hick’s contraction – painless and irregular.  Ultrasound – shows gestational sack. • Positive Signs o Conclusive for pregnancy o U my gosh! Buntis Me!  Ultrasound reveals fetal outline (sonogram).  Beating of the fetal heart audible (fetal heart tone). • Fetal heart beat – Doppler at 10 – 12 weeks; Stethoscope (18 – 20weeks). • Right lower quadrant.  Movement of the fetus felt by the examiner (fetal movement) • Fetal image through ultrasound scanning.  Health Habits during Pregnancy o Nutrition  Increase 300 kcal/day  Diets – increase calcium, iron, protein. o Weight gain  Increase to 25 – 35 pounds  1st trimester – total gain of 5 pounds.  4 – 8 months – per month – weight gain of 2 – 3 pounds  9th month gain 1 pound/week. o Hygiene practices  Paying attention to appearance – promote physical comfort.  Have dental check – ups  Avoid very cold or very hot baths. o Rest and sleep

 Recommend 8 hours of sleep at night.  At least one 15 – 30 min with or without sleep. o Physical activity  Can and should stay active.  Avoid contact sports but do keep active.  Nutrition during Pregnancy and Labor o Before pregnancy, if you were:  Underweight – gain 28 to 48 pounds.  Normal weight – gain 25 – 35 pounds.  Overweight – gain 15 – 25 pounds  Obese – gain 15 – 18 pounds. o Simple diffusion – transport oxygen to fetus o Organogenesis – 1st trimester. o Nutritional Requirement  Calorie increase: 800 kcal per day  Growth of the fetus  Placenta  Amniotic fluid  Maternal tissue o Important Nutrients Needed by Pregnant Women  CHON – 60 mg/day: metabolism – development of muscles.  Sources: meat, fish, poultry, and dairy products, beans.  Calcium – 1200 mg: dairy products, nuts dried fruits, canned salmon and sardines.  1000 – 1200 mg daily intake.  Iron – 30 mg/day: dried beans, fish, dried fruit, liver, nuts.  Iron is found in two forms: o Heme – red and organ meats. o Non heme – plant products.  Folic Acid – reduce incidence of neural tube defects.  RDA: 400 mcg (0.4 mg): liver o May cause meningomyelocele.  Fluids – 8 – 12 glasses/day; limit caffeine consumption to 2 cups/day.  Sodium Intake – restricted: edema and gestational HPN.  Iodine salt – better brain development. o Teenage Pregnancy  Girls growth and growth of fetus = difficult meeting nutritional needs.  Before pregnancy if you were:  Underweight: gain 35 – 40 pounds  Normal weight: gain 30 – 35 pounds  Overweight: 25 – 30 pounds o Health Hazards to Avoid During Pregnancy  STI’s  AIDS  Drugs – medications: should be advised by woman’s doctor and monitored.  Alcohol: can cause FAS and the baby will be shorter, weigh less, have a smaller head and have some heart problems.  Nicotine: can cause lack of oxygen to the unborn child and cause the baby’s brain to develop abnormally.

 Illegal drugs: can cause sever birth defects. If the woman is hooked on drugs, chances are the baby is too. The baby will go through a “withdrawal” once it is born.  Radiation exposure  Environmental pollution o Classification of Pregnancy  Gravida – number of times pregnant regardless of duration, including present pregnancy.  Primigravida – pregnant for the first time.  Multigravida – a woman who has 2 or more pregnancy.  Nulligravida – a woman who has never been pregnant.  Para – number of pregnancy that lasted more than 20 weeks regardless of outcome.  Primipara – a woman who has given birth to a baby beyond 20 weeks of gestation.  Multipara – had two or more births to a baby beyond 20 weeks of gestation.  Nullipara – has not given birth to a baby beyond 20 weeks of gestation.  Postdate/post term – beyond 42 weeks of gestation.  Preterm – has reached 20 weeks of gestation but before completion of 37 weeks of gestation.  Term – a pregnancy from beginning 38th week of gestation to the end of the end of the 42nd weeks of gestation.  Viability – capacity to live outside the uterus approximately 22 – 24 weeks since LMP or weight of fetus is greater than 500 grams.  TPAL – para subdivided to reflect births that went Term, Premature births, Abortion, and Living children. 4. FETAL ASSESSMENT • Fetal diagnostic tests o Used to:  Identify or confirm existence of risk factors.  Validate pregnancy.  Observe process of pregnancy.  Identify genetic abnormalities. o Chronic Villi Sampling (CVS)  Provides chromosomal studies of fetal cells.  Getting a sample of the chronic villus (placental tissue)  Done at 10 – 12 weeks of gestation  1 % risk of confined placental mosaicism o Amniocentesis  Small amount of fluid from the amniotic sac is withdrawn to look for the birth defects and chromosome problems.  15 – 20 weeks gestation  Detects: down’s syndrome, spina bifida, fetal lung maturity.  For Rh – incompatibility. o Ultrasound / sonogram  Sound waves bounce of the fetus to produce an image of the fetus inside the womb.  Determines gestational age.  Diagnose multiple pregnancies.  Identify congenital anomalies

Fetal viability. • Types: o Trans vaginal UTZ – used during early pregnancy. o Standard UTZ (2D) o 3D – more detailed o Doppler UTZ – provides information about blood flow and assess heart beat.  Cleft lip  Gastrochisis o Fetal Kick Counts  Determines FHR. Normal: 120 – 160 bpm  Recognizes periodic change in FHR.  Determines frequency and duration of contractions. • 10 movements in 2 hours. o Percutaneous Umbilical Blood Sampling (PUBS) or cordocentesis  A blood sample is withdrawn from the umbilical cord for testing.  Specifically use to diagnose disease of the blood. E.g. thrombocytopenia  Can receive weekly • Infusion of platelets until delivery. o Nonstress test (NST)  Accelerations in heart rate accompany normal fetal movement.  Use to assess FHR on a frequent basis in order to ascertain fetal well – being.  Performed after 28 weeks gestation. o Contraction Stress Test  Monitor fetus response to contraction to determine well being obtain through: • During spontaneous Braxton Hick’s contraction • Nipple stimulation CST: massage or rolling of one or both nipples to stimulate uterine contraction. • Oxytocin challenge test: infusion of calibrated dose of IV oxytocin.  The woman must have at least 3 contractions, 40 seconds in duration in a 10 minute period for interpretation of the CST.  Fetus can tolerate labor.  Consistent late deceleration  May try induction or CS birth. o Biophysical Profile  Measurement of 5 biophysical variables to determine fetal well – being: • FHR acceleration • Breathing • Body movements • Muscle tone • Amniotic fluid volume Leopold’s Maneuver o Purpose: to determine the position and presentation of the fetus : identify if the pelvis measurement is appropriate enough for NSD. o Procedures:  Preparation: 

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Ask pregnant mother to void before you palpate so as to make her comfortable and fetal contours are not obscured by a distended anterior urinary bladder. • Should be supine with knees flexed slightly to relax the abdominal muscle from contracting or lightening • Warm hands, uncover the abdomen. Use firm, gentle motion in executing the 4 maneuvers. st  1 Maneuver • Face head part of the woman. o Palpate superior surface of the fundus or upper part of abdomen with tips of both hands. o Form a precise opinion as to what fetal part has in this area.  Fetal head is hard, firm, round, moves independently of the trunk.  A buttock feels softer, is symmetric and has small bony… o  2nd Maneuver • Face head part of the woman • Determine the location of the fetal back. o Fetal back is smooth, hard, firm, resistant surface. o Fetal extremities feel like small irregularities and protrusion. rd  3 Maneuver • Pawlick’s grip • Still facing the head part of the woman. • Determine what fetal part is lying above the inlet or lower abdomen. th  4 Maneuver • Face the foot part of the woman. • Locate the fetus brow. • Degree of flexion. Area for Abdominal Palpation Assess fundal height  Fundal height (cm) approximate weeks of gestation. Assess fetal lie  Relationship of the long axis (spine) of the fetus to the long axis of the mother. Assess fetal presentation  Part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor term. Asses fetal vertex position  LOL – 40 %  LOA – 12%  LOP – 3%  ROL – 25%  ROA – 10%  ROP – 10 % Assess fetal descent  Is vertex engaged  4 presenting parts

• Occiput – vertex presentation • Chin (mentum) – face presentation • Sacrum – breech presentation • Scapula (acromion) – shoulder presentation. 5. COMPLICATIONS DURING PREGNANCY • Hemorrhagic Conditions o Abortion  The spontaneous or induces abortion of a pregnancy before viability of the fetus.  Viability is defined as 20 – 24 weeks of gestation and a weight of 500 g.  Induced – voluntary method of termination. • Factors: o Preserve the health of the mother. o Prevent the birth of an infant with severe genetic defects. o End pregnancy cause by rape or incest. o Economic or social reasons. • Methods o Vacuum aspiration o Pills (drugs)  Mifepristone (RU [roussel u-claf] 486)  Misoprostol (cytotec) – prostaglandin  Methotrexate (cancer drug)  Spontaneous Abortion • Commonly known as miscarriage. • Factors: o Chromosomal abnormalities o Faulty implantation o Teratogenic substances o Placental abnormalities o Incompetent cervix o Chronic maternal disease o Maternal infections o Endocrine imbalances • Classification o Threatened  Unexplained bleeding and cramping, cervix is closed and membranes are intact. o Inevitable  Increase bleeding and cramping, the cervix begins to dilate and the membranes may rupture. o Incomplete  Some of the products of conception are expelled; most often the placenta is not expelled; bleeding is heavy and cramping is severe. o Complete  All products of conception are expelled. o Missed

Embryo or fetus dies but is retained; the cervix is closed; if the fetus is not expelled within 6 weeks, disseminated intravascular coagulation may develop. Habitual  Any of the above occurring in 3 consecutive pregnancies; most commonly the cervix begins to dilate in the 2nd trimester; this is called an incompetent cervix. 

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Management  Limit activities for 24 – 48 hours  Avoid stress, fatigue, strenuous activity and sexual intercourse if bleeding stops.  Increase rest periods until pregnancy seems to be progressing normally.  Dilatation and curettage or suction evacuation is performed to remove the products of conception from the uterus for inevitable or incomplete abortion.  Blood transfusion may be given depending on the amount of blood loss.  Induction of labor for missed abortion in 12 weeks AOG and D&C for less 12 weeks AOG and below.  Cerclage for habitual abortion caused by incompetent cervix. (Shirodkar) Procedure suture material is placed on the cervix in a purse string fashion at the level of the internal os done about 16 weeks AOG. o Nursing Considerations  Prevention or identification of hypovolemic shock • Tachycardia • Falling BP • Pale skin and mucous membranes • Confusion • Restlessness • Cool, clammy skin.  Emphasize that spontaneous abortion usually occur because of factors or abnormalities that could be avoided.  Provide emotional support.  Recognize the meaning of the loss to each family member.  Provide information with brief and simple explanation. Ectopic Pregnancy o Implantation of a fertilized ovum in an area outside the uterus cavity. o Ampulla of fallopian tube (90%) o “A disaster of reproduction”  Leading cause of maternal mortality due to hemorrhage.  Reduces the chance for woman for subsequent pregnancy. o Risk factors  History of STIs, PID, previous ectopic pregnancy  Failed tubal ligation  IUD  Multiple induced abortion  Maternal age: > 35 years old o Clinical manifestation o

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 Missed menstrual period  Abdominal and pelvic pain  Vaginal spotting or light bleeding  Profuse hemorrhage  Signs of hypovolemic shock o Diagnostics  Transvaginal UTZ  Serum hormone level • Progesterone • HCG  Culdocentesis – insertion of needle to upper posterior part of the vaginal wall to aspirate pelvic fluid.  laparoscopy o Management  Methotrexate • Explain adverse side effects. • Instruct to refrain from alcohol and folic acid • Avoid sexual intercourse. • Emphasize follow – up appointments  Linear salphingotomy • Incision along the fallopian tube • No suture to the opening to prevent scarring.  Salphingectomy Hydatidiform Mole o Gestational trophoblastic disease o Proliferation and degeneration of the trophoblast villi where the fertilized ovum dies and the chorion develops into vesicles (grape – like clusters). o Choriocarcinoma, possible infection. o Types:  Complete • All trophoblastic villi swell and become cystic • Has only paternal genetic material • No fetus present  Partial • Some of the villi form normally • There is a fetus with multiple chromosomal … o Clinical Manifestations  Elevated HCG  Vaginal bleeding (dark brown spotting to profuse hemorrhage)  Uterus larger than expected for the duration of the pregnancy.  No FHT  Excessive nausea and vomiting due to increased HCG  Early development of PIH – occur 24 weeks after AOG o Diagnostic  Ultrasound o Management  Immediate evacuation of the mole  Vacuum aspiration followed by curettage  Pre • Chest radiography, CT scan or MRI

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• CBC, blood typing and cross matching.  Post • IV oxytocin  Follow up to detect malignant changes in the remaining trophoblastic tissue. Placenta Previa o Implantation of the placenta in the lower uterine segment in advance of the fetal presenting part. o Types:  Complete – placenta completely covers the internal os  Partial – partially covers the internal os.  Marginal – placenta just reaches the internal os but doesn’t cover it.  Low – lying placenta – extends into the lower uterine segment but doesn’t reach the internal os. o Clinical Manifestation  Spotting  Painless uterine bleeding o Diagnostics  Transabdominal sonography  Transvaginal sonography o Precautions  No IE; DRE; oxytocin o Management  Aim: maintain the pregnancy until the fetus is mature enough to survive outside the uterus.  Conservative Management • Home care o Criteria  Client is stable with no evidence of active bleeding.  Client can remain on bed rest at home  Home is within reasonable distance from the hospital.  Emergency transportation is available 24 hours a day. • Inpatient care o Manage patient in the hospital  FHR monitored as well as bleeding.  Fetal activity.  Cesarian Birth • Factors o > 36 weeks AOG o Excessive bleeding o Unstable cardiovascular status o Signs of fetal compromise  Betamethasone (celestone) • Accelerates lung maturation o Nursing Considerations  Monitor bleeding  Bed rest with O2 as prescribed  Positioning: side lying or trendelenburg

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 Monitor fetal status  Keep IV line and make blood available. Abruptio Placenta o Premature separation from the wall of the uterus of a normally implanted placenta. o Occurs spontaneously after the 20th week of gestation in 1 out of 75 – 90 pregnancies. o Types:  Central AP • Center of the placenta separates with blood trapped between placenta and the uterine wall. • No apparent bleeding  Marginal AP • Edge of placenta separates with profuse bleeding apparently vaginally.  Complete AP • Entire placenta separate with profuse bleeding apparent vaginally. o Contributory Factors  Trauma  Short umbilical cord or uterine anomaly  Maternal hypertension  Multiple pregnancy  Smoking  Use of alcohol or cocaine o Clinical Manifestation  Vaginal bleeding  Tender and painful abdomen (board like)  Couvelaire uterus o Complication  Pre term labor  Anemia  Irreversible brain damage  Fetal death o Diagnostic  Ultrasound o Management  Aim: rational plan for delivery of the fetus  Intravenous fluid (LRS)  Induction of labor if the separation is small and pregnancy is near term.  Amniotomy  Caesarian birth is performed if labor is not progressing in 8 hours.  Tocolytic medication (ritodrine[Yutopar])  Bed rest until situation is stable Vasa Previa o Refers to fetal vessels running through the membranes over the cervix and under the fetal presenting part unprotected by placenta or umbilical cord. Placenta Accreta o Any placental implantation in which there is abnormally firm adherence to the uterine wall.

Types:  Placenta increta – myometrium  Placenta percreta – surpass the myometrium  Total PA – all cotyledons are attached to the myometrium  Partial PA – some cotyledons are attached to the myometrium  Focal PA – only one cotyledon is attached to the myometrium • *asherman’s syndrome – adhesion after CS • Hysterectomy; hysteroscopy + adhesiolysis Hyperemesis Gravidarum o Persistent uncontrollable vomiting during pregnancies. o Excessive vomiting of pregnant women o Causative Factors  Hormonal changes • Increased HCG, estrogen and progesterone [delay GIT motility]levels (salivation) • Psychological factors  Complications • Weight loss • Dehydration • Vitamin deficiency  Diagnostic • Laboratory studies (HGB & HCT; serum electrolytes)  Management • IV rehydration • TPN as necessary • Antiemetic drugs  Nursing considerations • Reducing nausea and vomiting o Dry crackers or toast o Rise slowly from bed o Small frequent feeding o Drink fluids in between meals o Avoid greasy or spicy foods • Maintaining nutrition and fluid balance o IVF and TPN as directed o Increase K and Mg intake o Clear fluids are started as N&V subside. • Providing emotional support Disseminated Intravascular Coagulation o Over stimulation of the normal clotting process o Rapid massive fibrin formation causes small thrombi to form throughout the circulatory system depleting the clotting factors and platelets. o Causative factors:  Premature separation of the placenta  PIH  Placental retention  Amniotic fluid embolism  Septic abortion  Dead fetus retention o Clinical Manifestation o

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 Bruising or bleeding from the IV site  Dyspnea / chest pain  Restlessness  Cyanosis  Frothy, blood – tinged mucous o Diagnostics  HGB  HCT  Fibrinogen level  Prothrombin time  Partial thromboplastin time o Management  Facilitate delivery if the fetus is not yet born  Administration of blood fibrinogens  Continuous administration of heparin  Oxygen therapy Pregnancy Induced Hypertension o Multiorgan disease process that develops during pregnancy and regresses in the post partum period o Most common hypertension disorder in pregnancy o Appears after 20 weeks of gestation o Risk factors:  Primigravida • In lower socio-economic group • With poor nutritional status  Mother with history of • Diabetes • Multiple pregnancy • PIH o Clinical Manifestation  Hypertension  Edema  Proteinuria o Classification  Gestational Hypertension • Elevated BP of 140/90 mmHg • No proteinuria or edema • No drug therapy is necessary  Mild Pre – eclampsia • BP: increase 30 mmHg (systole)/ increase 15 mmHg (diastole) over the client’s baseline BP on 2 occasions at least 6 hours apart. • Edema may be noted in the face and hand • May show 1+ or 2+ albumin on a dipstick or 300 mg / L in 24 hours.  Severe pre – eclampsia • BP increases 160/110 mmHg or higher on 2 occasions of 6 hours apart. • Generalized edema on the face, hands sacral area, lower extremities or abdomen. • Urinary albumin is 3+ or 4+ in a dipstick

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Urine output may drop to lower than 500 mL / 24 hours. Elevated hematocrit, uric acid and serum creatinine levels Other clinical manifestations o Continuous headache o Scotomata (spots before the eyes) o N and V o Irritability o Hyper reflexia o Cerebral disturbances o Pulmonary edema o Epigastric pain (last symptom identified before the client moves into eclampsia.  Eclampsia • Grand mal seizures with tonic (pronounced muscular contraction) and clonic (alternate contraction and relaxation of muscle) phase. • A client sleeps into a coma from minutes to hours. • Seizures/coma sequence can be repeated one or more time and death may follow. o Chvostek’s sign o Trousseau’s sign  HELLP syndrome • PIH with liver damage • Characterized by HELLP o Hemolysis is caused when intra-arterial lesions develop due to vasospasm causing platelets to aggregate and a fibrin network to be formed; the RBC are forced through the fibrin network and lysis resulting in large drop in hematocrit. o Elevated liver enzymes may be due to microemboli in the vessels of the liver causing ischemia o Low platelet counts result when the platelets are entrapped at the intra-arterial lesions o Results to ischemia and tissue damage o May show signs of hypoglycemia. • Management o Goal: lowers BP, prevent convulsion and deliver a healthy baby o Complete bed rest for client’s mild preeclampsia with increase renal and placental blood flow. o Monitor laboratory data o Caesarian birth o MgSO4 o Hydralazine o Sedative may be given to let the client rest quietly o Oxytocin may be given to induce labor Gestational Diabetes Mellitus o General Information  Chronic disease caused by improper metabolic interaction of carbohydrates, protein, fats and insulin  Interaction of pregnancy and diabetes may cause serious complications of pregnancy  Classifications of Diabetes mellitus:

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Type 1: formerly called juvenile-onset or insulindependent diabetes; onset before age 40 • Type 2: formerly called maturity-onset or non-insulindependent; onset after age 40 • Type 3: formerly called gestational; onset during pregnancy; reversal after termination of pregnancy • Type 4: formerly called secondary; occurs after pancreatic infections or endocrine disorder o Significance of Diabetes in pregnancy  Interaction of estrogen, progesterone, HPL and cortisol raise maternal resistance to insulin (inability to use glucose at the cellular level).  If the pancreas cannot respond by producing additional insulin, excess glucose moves across placenta to fetus, where fetal insulin metabolizes it and acts as growth hormone, promoting macrosomia.  Maternal insulin levels need to be carefully monitored during pregnancy to avoid widely fluctuating levels of blood glucose.  Dose may drop during first trimester, then rise during second and third trimesters.  Higher incidence of fetal anomalies and neonatal hypoglycemia (good control minimizes) o Assessment Findings  Polyuria  Polydipsia  Weight loss  Polyphagia  Elevated glucose levels in blood and urine. Urine tests for elevated blood glucose less reliable in pregnancy. Blood tests (more accurate) used as follows: • 1-hour glucose tolerance test: usually done for screening on all pregnant women 24-28 weeks pregnant. • 3-hour glucose tolerance test: used where results from 1hour GTT> 140 mg/dl. • HbAlc: glycosylated hemoglobin; reflects past  4-12 week blood levels of serum glucose. o Nursing Interventions  Teach client the effects and interactions of diabetes and pregnancy and signs of hyper- and hypoglycemia  Teach client how to control diabetes in pregnancy, advice of changes that need to be made in nutrition and activity patterns to promote normal glucose levels & prevent complications.  Advice client of increased risk of infection and how to avoid it.  Observe and report any signs of preeclampsia  Monitor fetal status throughout pregnancy  Assess status of mother and baby frequently  Monitor carefully fluids; calories, glucose and insulin during labor and delivery  Continue careful observation in post delivery. • Rh incompatibility B. Intrapartal Period • Extends from the beginning of contractions that causes cervical dilatation to the 1st 4 hours after delivery of the newborn and placenta.

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Labor o Process by which the fetus and products of conception are expelled as the result of regular, progressive, frequent, strong uterine contractions. o Theories Explaining Onset Of Labor  Uterine Stretch Theory • A hollow organ such as the uterus when full will empty.  Oxytocin Theory • Oxytocin released by the posterior pituitary gland initiates labor.  Progesterone Deprivation Theory • Contraction initiated when progesterone level are decreased as such at the end of pregnancy.  Prostaglandin Cascade Theory • Labor is initiated due to the production of prostaglandin as a result of interplay between adrenal, fetus and uterus.  Aging Placenta Theory o Components of Labor and Delivery  Power • Forces that cause the cervix to open and propel the fetus through the birth canal. • Uterine contraction o Primary power of labor o Characteristics  Involuntary contraction • Spontaneous contraction • Cervix dilatation and effacement of the cervix during the 1st stage of labor • Phases: Increment (gain strength). Acme (peak), Decrement (letting go)  Intermittent Contraction • Description o Frequency o Duration o Intensity o Regularity • Maternal Push o Voluntary beating down efforts o After full dilatation of the cervix o Efforts similar to those of defecation o Contraction of levator ani muscle  Passenger • Refers to the fetus plus the membranes and placenta • Fetal skull and fetal accommodation to passageway affects the labor progress. • Indication of fetal head o Largest part of the body o Common presenting part o Least compressible fetal part  Cranial bones • Frontal – 1 • Parietal – 2 • Temporal – 2

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Occipital – 1 Sphenoid – 1 Ethmoid - 1

Suture line o Intermembranous spores o Allows molding – overlapping of the sutures o Sagittal – 2 parietal o Coronal – parietal and frontal o Lamboidal – parietal and occipital Fontanels o Anterior fontanel  4 cm in any direction – normal size  Diamond in shape  Closes at 12 – 18 months o Posterior fontanel  < 1 cm – normal size/location  Triangular in shape  Closes 2 – 3 months Measurements o Transverse diameter  Biparietal – largest at 9.5 cm  Bitemporal – 8 cm  Bimastoid – smallest at 7 cm o Antero-posterior diameter  Sub-occipito bregmatic – 9.5 cm  Occipito – frontal – 12 cm  Occipito – mental – 13.5 cm  Submento bregmatic – face presentation Fetal Accommodation to the Passageway o Fetal Lie  Transverse  Longitudinal  Oblique o Presentation  Cephalic • Vertex – head is completely flexed, chin touching chest • Sinciput – anterior fontanel is the presenting part • Brow – head is bent back causing the occipitomental diameter • Face presentation • Chin presentation  Breech / buttock / lower extremities presentation • Frank - thighs flexed, legs extended on anterior body surface, buttocks presenting • Full or complete – squatting presentation • Footling – one or both  Shoulder / horizontal / transverse presentation  Compound presentation

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Presentation occurs when there is prolapsed of the fetal head alongside the vertex, breech or shoulder.

Position  Relationship of the landmark on the presenting part to the front, side, and back of the maternal pelvis.  Maternal side 1st – refer to the side of the maternal pelvis in which the part is found right or left. • Fetal presentation side o Occiput (O) – vertex or military o Frontum/ brow (FR) – brow o Mentum / chin (M) – face o Sacrum (S) – breech o Scapula (Sc) - shoulder  Maternal quadrant • Side of the maternal pelvis which the reference point is found. • Anterior – front of the pelvis • Posterior – back • Transverse - side  Most common positions • LOA – favorable delivery position o Facing the lower left abdomen • ROA – fetal occiput on maternal side • LOP – maternal side and toward back, face is up o Labor is slowed and much back discomfort on mother during labor. • ROT – occiput is facing the right side and looking toward the left side. Attitude or Habitus  Describes the degree of flexion a fetus assume during labor or the relationship of fetal part to each other  Full flexion (Vertex) – good attitude – normal fetal position • Presents the smallest anterior diameter  Moderate flexion (sinciput)  Chin not touching the chest (military)  Partial extension (Brow) – brow of head to the birth canal  Complete extension (face) Station  Descent of the fetal presenting part in relationship to the level of the ischial spine  0 – level of ischial spine  -3 to -1 – above the ischial spine  +1 to +3 – below the ischial spine Engagement

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Settling of the presenting part of a fetus far enough into the pelvis to determine the level of ischial spine

Passageway •

Maternal pelvis o

False pelvis – part of the bony passageway

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True pelvis 

Landmark: inlet (entrance to the midpelvis); outlet (exit point)

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Measurements – estimate size of true pelvis •

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Obstetric conjugate – smallest diameter of the inlet where fetus must pass o

1.5 – 2 – form diagonal conjugate for approximation.

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11 cm – adequate to accommodate delivery

Diagonal conjugate – distance from the promontory of the sacrum to the lower.

Pelvic shapes o

Android

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Anthropoid

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Gynaecoid

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Platypeloid

Psyche •

Physical preparation of childbirth

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Three Categories o

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Psychophysical 

Bradley’s method – presence of husband

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Dick Read method – fear produces tension, pain

Psychosexual

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Ketzinger’s method – states that pregnancy, labor, birth, and care of newborn are an important turning point in woman’s cycle.

Psychoprophylactic 

Lamaze – requires discipline, conditioning and concentration

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Prevention of pain •

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Features: o

Conscious relaxation

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Cleansing birth inhaling to the nose and mouth exhaling

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Effleurage – light abdominal massage

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Cultural heritage

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Previous experience – complication of delivery and mode of birth outcome

Methods of Delivery  Birthing chair – semifowler position  Birthing bed – dorsal recumbent  Squatting position – relieves local pain and facilitate descent  Leboyer’s method – quiet and calm environment, soft music, dark lighted room  Birth under water Signs of Labor and Delivery  Culmination of pregnancy but the beginning of parenting.  Pre – eminent signs of labor • Lightening / engagement o Presenting part of the fetus descends to pelvic brim • Weight loss o Decreased 2 – 3 pounds around 1 – 2 days before onset of labor • Increased activity level • Increased Braxton hick’s contraction • Diarrhea – result of increases nerve enervation due to descent • Ripening of cervix • Bloody show – 1st sign o Mixture of thick mucous and pink or dark brown blood. o Pink – tinged mucus vaginal discharge • Rupture of membranes o There is danger of cord prolapsed if fetal head is not engaged and serious infection.

Labor and delivery will most probably occur within 24 hours Nursing Management • Assess FHR for 1 full minute • Assess color of amniotic fluid o Normal: clear or straw colored with specs of vernix caseosa o Green – tinged: fetal distress o Yellow colored: hemolytic disease, hyperbilirubinemia o Gray or cloudy: infection o Pinkish/ red stained: bleeding o Brownish/ tea colored/ coffee colored – fetal death. • Record time and rupture, characteristics of fluid and FHR o

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Contraction

Discomfort Rest and Activity Cervix o

TRUE Regular Increase frequency, duration and intensity Shortening of interval Radiates from back Around the abdomen Contraction does not decrease with rest or activity/ walking Progressive effacement and dilatation of cervix

Danger Signs of Pregnancy Signs Swelling of face, finger, legs Headache, continuous and severe Abdominal / chest pain Vaginal bleeding Vomiting, persistent Visual changes Escape of vaginal fluids

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FALSE Irregular No change in frequency, duration and intensity Pain at the abdomen Contraction may lessen with activity or rest Cervical changes do not occur.

Possible cause PIH, thrombophlebitis (Leg) PIH Ectopic, uterine rupture, pulmonary embolism Placental problems Infection (also with fever and chills), hyperemesis gravidarum PIH PROM

Progress of Labor o Engagement, Descent and Flexion o Internal Rotation o Extension  Extension complete (delivery of fetal head)  Aspiration of mouth o External rotation  Delivery of shoulder o Expulsion Stages of Labor Phases Dilatation Duration

Intensity

1st Stage

2nd Stage

I (Latent)

0 – 3 cm

II (Active)

4 – 7 cm

III (Transition)

8 – 10 cm

Phases

Dilatation

Contraction

I

0 - +2

II

+2 - +4

III

+4 - birth

2 -3 min apart 2 – 2.5 min apart with urgency to bear down 1 – 2 min apart, fetal head visible with increased urgency to bear down

3rd Stage

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Mild to moderate Moderate to severe Severe

Placental delivery Sudden gush of blood, lengthening of the cord, rising of the fundus, globular uterus 4th Stage 1st 4 hours after delivery of the placenta (v/s, fundus and lochia monitoring every 15 minutes until stable.) Nursing Considerations o Monitor v/s, FHR o Provide comfort measures  Ambulation  Side lying position  Sacral pressure  Back rubs o Breathing technique during transition phase o Evaluate placental completeness Complications of Labor and Delivery o Preterm Labor  Begins after the 20th week but before the end of 37th week of pregnancy.  Biochemical markers • Fetal fibronectins – glycoprotein found in the plasma (vaginal swab test). • Salivary estriol – form of estrogen (salivary swab test).  Risk factors • Previous preterm labor • Abdominal surgery • Younger than 18 years old • Older than 40 years old • Low socio – economic class • Abnormality of fetus or placenta -

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10 – 30 sec 5 – 30 min 30 – 40 sec 3 – 5 min 45 – 90 sec 2 – 3 min

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• Multiple gestation • Emotional and physical stress • Nutritional deficiency  Clinical Manifestations • Uterine contractions (painful/less) • Abdominal cramps (menstrual cramps; with/out diarrhea) • Constant low back ache • Sensation of pelvic pressure • Change or increase in vaginal discharge • A sense of “just feeling bad” or “coming down with something”.  Management • Focus: prevention of delivery of premature fetus. • Identify and treating infections – UTI • Restricting activity – left side lying position (increasing placental blood flow, prevent hypotension; decrease fetal pressure on the cervix). • Hydrating the woman • Tocolytic therapy o Ritodrine (Yutopar) o Terbutaline (Brethine) o MgSO4 – anti – convulsant o Prostaglandin synthesis inhibitor • Accelerating fetal lung maturity o Corticosteroid – within 24 hours, it will be effective  Betamethasone  dexamethasone Premature Rupture of Membranes  Rupture of the amniotic sac before the onset of true labor, regardless of length of gestation.  Preterm Premature Rupture of Membranes • Earlier than end of 37th week  Causative Factors • Vaginal or cervical infections – gonorrhea • Chorioamnionitis • Incompetent cervix • Fetal abnormalities or malpresentation • Hydramnios • Amniotic sac with a weak structure • Recent sexual intercourse • Nutritional deficiencies  Management • Prevent complications • Oxytocin induction or caesarean birth  Nursing considerations • No coitus or douching • Avoid breast stimulation • Monitor temperature (> 37.8 degrees celcius) • Maintain bed rest (50 % effective)

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Precipitate Labor  Precipitous labor  Labor that lasts less than 3 hours from the onset of contraction to the time of birth.  Occur when uterine contraction are so strong that the woman given birth wit only a few rapid occurring contractions.  Tetanic intensity of contractions  Complications • Mother o Uterus rupture o Laceration of the birth canal o Post partum hemorrhage • Fetus o Hypoxia (brain) – caused by decreases periods of uterine relaxation. o Subdural hemorrhage – due to rapid birth  Induction and Augmentation of Labor • Use of artificial method to stimulate uterine contractions • Indications o PIH o Spontaneous ROM at or near term without labor o Chorioamnionitis o Maternal medical conditions that are worsening with continuation of pregnancy (DM, pulmonary diseases) o Conditions in which the intrauterine environment is hostile to fetal well – being. • Pre – induction o Fetus is longitudinal lie o Cervix is ripe/ ready for birth o A presenting part is engaged o No CPD o Fetus is estimated to mature by date (L/S ratio or sonogram)  Scoring of effacement of cervix • Techniques / methods o Amniotomy  Artificial rupturing of membranes using amniotomy forceps (allis, amnihook – perforator)  Indications • To reduce or augment labor • To perform internal fetal monitor • To determine color of amniotic fluid when fetal compromise is suspected. • To prevent aspiration of the contents of the amniotic sac at the moment of birth  Nursing Considerations • NPO before amniotomy

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Ascertain fetal lie, position and presentation (UTZ, palpitation) • Explain the procedure • Immediately after the rupture, check FHR • Note color, amount of amniotic fluid • Note time of rupture (prevent dry labor and infection). Oxytocin Administration  Average: 10 – 20 units  Maximum: 80 units  Precautions: • Diluted in a physiologic electrolyte containing fluid and given as secondary (piggyback) infusion.(to easily stop when there is hypertonic contractions.) • Started slowly, increased gradually and regulated with an infusion pump • Monitor uterine activities and FHR.

Dystocia  Prolonged and difficult labor  Also known as • Difficult labor / childbirth • Abnormal labor / childbirth • Dysfunctional labor  Types: • Uterine dysfunction o Abnormalities of the powers  Hypotonic uterine dysfunction  Hypertonic uterine dysfunction  Inadequate secondary force • Abnormalities with the passageway o Pelvic dystocia  Inlet; midpelvis, outlet dystocia o Soft tissue dystocia  Placenta previa  Tumors that distend the birth canal o Fetal dystocia; abnormalities of the passenger  Malposition  Breech presentation  Face presentation  Brow presentation  Shoulder presentation  Multiple presentation  Macrosomia (large babies)  Hydrocephalus Uterine rupture  Tear in the wall of the uterus that occurs because it cannot withstand the pressure against it.

Variations • Complete – includes broad ligament and the peritoneal cavity. o Sudden excruciating pain at the peak of contraction. • Incomplete – the broad ligament is included but not the peritoneal cavity o Localized tenderness and persistent pain on the abdomen. • Dehiscence – partial separation of an old uterine scar  Clinical Manifestation • Abdominal pain and tenderness • Chest pain between the scapula or on inspiration • Hypovolemic shock after birth • Signs associated with impaired fetal oxygenation (bradycardia, delayed deceleration). • Absent FHT • Cessation of uterine contraction • Palpation of fetus outside the uterus  Management • Stabilize the woman and fetus • Perform cesarian delivery • Hysterectomy o Considerations: consent from both parents and age factor.  Nursing Considerations • Infuse BT and IVF as ordered • Administer oxytocin cautiously • Monitor for hypertonic contractions and notify physician. • Post – op o Avoid driving (3 - 6 weeks) o Avoid jogging, sexual intercourse, dancing, lifting heavy objects (6 – 8 weeks) Prolapsed Umbilical Cord  Occurs when the cord passes out of the uterus ahead of the presenting part.  Risk factors • Fetus that remains at a high station • A very small fetus • Breech presentation • Transverse lie • Hydramnios • Long cord • Placenta previa  Clinical Manifestation • Completer prolapse – visible on the vulva • Occult prolapse – cord slips alongside with the head or shoulder of fetus • Changes in FHR (bradycardia)  Management 

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Focus: to relieve pressure on the cord to restore blood flow through it until delivery. • Position the woman hip higher than her head to shift the fetal presenting part toward her diaphragm. o Knee chest o Trendelenburg o Hips elevated with pillows, with side lying position maintained. • With gloved hand, push the fetal presenting part upward. • Oxygenation at 8 – 10 LPM via face mask. • Tocolytic drug, terbutaline (inhibit contraction; increase placental blood flow) • Warm saline – moistened towels retard cooling and drying of cord. Nursing considerations • The nurse must remain calm and acknowledge the woman’s anxiety. • Simple explanation of the condition. • Include the family (decision making).