Obstetric Nursing Revised

OBSTETRIC NURSING

Dante Roel Fernandez, RT, MD

NORMAL MENSTRUAL FLOW • Mean interval – 28 days(+/- 7 days) • Duration – 4 to 7 days • Mean amount of menstrual blood loss – 35 mL

Days Name of phase menstrual phase

1–4

follicular phase (coincides with proliferative phase)

5–13

ovulation (not a phase, but an event dividing phases)

14

luteal phase (coincides with secretory phase)

15–26

ischemic phase (some sources group this with secretory phase) 27–28

MENSTRUAL CYCLE

Endometrial changes Proliferative (Follicular) phase  depends on ESTROGEN produced by GRANULOSA CELLS of the ovarian follicles under the stimulation of FSH

Secretory (Luteal) phase  depends on PROGESTERONE produced by the LUTEAL CELLS of the CORPUS LUTEUM

Endometrial changes Menstrual phase  depends on withdrawal of PROGESTERONE assuming pregnancy does not occur  the entire endometrial zona functionalis layer sheds

Understanding…

• Menstrual Cycle • ..\..\..\OTHERS\Menstrual Cycle.s

NORMAL Regular frequency Normal amount and duration MENORRHAGIA Regular frequency Increased in amount and duration Cycle 21-35 days HYPOMENORRHEA Regular frequency Decreased in amount and duration Cycle 21-35 days

POLYMENORRHEA Regular frequency Normal amount and duration Cycle<21 days OLIGOMENORRHEA Regular frequency Normal amount and duration Cycle>35 days METRORRHAGIA Menstrual bleeeding between normal cycles MENOMETRORRHAGIA Irregular frequency Increased in amount and duration

At what age does menstruation typically begin? • Average age of 12 • However, girls can begin menstruating as early as 8 years of age or as late as 16 years of age • Women stop menstruating at menopause, which occurs at about the age of 50

What are some of the symptoms of a normal menstruation? Moodiness Trouble sleeping Food cravings Development of cramps Bloating Tenderness in the breasts

What symptoms may indicate a need to contact my doctor about my period? You have not started menstruating by the age of 16 Your period stops suddenly You are bleeding for more days than usual You are bleeding more heavily than usual

What symptoms may indicate a need to contact my doctor about my period? You have bleeding between periods that is more than just a few drops You suddenly feel sick after using tampons You think you might be pregnant—for example, you have had sex and your period is at least five days late

FERTILIZATION • Per ejaculation the average of 2.5 ml of seminal fluid contains 50-200 million spermatozoa per ml or 400 million per ejaculation • Occurs in the outer third of fallopian tube • Upon fertilization, the resulting structure is called the ZYGOTE!

IMPLANTATION • It takes 3-4 days for the ZYGOTE to journey to the uterus(where implantation takes place) and during such journey mitotic division occurs. • Zygote free floats for the next 3-4 days, the morula grows to become a BLASTOCYTES with TROPOBLAST. • Implantation occurs at high and posterior portion of the uterus. • Structure is called EMBRYO until 5-8 weeks when it begin to be referred to as FETUS.

Fetus • From the eight week to birth, the growth and development of systems essential to life.

Neonate

• An infant that is between birth and 28 days of age.

Antenatal or Antepartum

• The period from conception to the onset of labor

Intrapartum • The period of time from the onset of labor until the birth of the baby and delivery of the placenta

Postpartum

• The period from birth to 42 days (6weeks) after birth

WHAT IS GOODELS SIGN? • IT IS THE SOFTENING OF THE CERVIX • OBSERVABLE BY 6-8 WEEKS GESTATION.

WHAT IS HEGARS SIGN? • SOFTENING OF THE LOWER UTERINE SEGMENT, BEGINS AS EARLY AS 5 WEEKS GESTATION

WHAT IS CHADWICKS SIGN? • VAGINAL MUCOSAL CHANGE IN COLOR FROM PINKISH TO PURPLISH OR DARK-BLUISH.

EASY WAY TO REMEMBER THE SIGNS: • CHADWICKS  VAGINA • GOODELS  CERVIX • HEGARS  UTERUS

Estimated Date of Delivery

• The date is determined by using Naegel’s rule

Naegel’s rule • Method for calculating the estimated date of confinement (EDC/EDD) • EDC/EDD = - 3 months + 7 days + 1 year

OB Scoring • Flight • Philippine • Air • Lines

 Full term  Preterm  Abortion  Living children

BARTOLOME’S RULE • FUNDIC HEIGHT IS MEASURED BY PALPATION AND BY RELATING TO THE DIFFERENT LANDMARKS IN THE ABDOMEN, UMBILICUS, SYMPHYSIS PUBIS AND XIPHOID PROCESS.

LOCATION OF THE FUNDUS

• 12 WEEKS- at the level of symphysis pubis • 16 WEEKS- halfway between symphysis pubis and umbilicus • 20 WEEKS- at the level of the umbilicus • 24 WEEKS- two fingers above umbilicus • 30 WEEKS- midway between umbilicus and xiphoid process • 36 WEEKS – at the level of xiphoid process • 40 WEEKS- two fingers below xiphoid process

Gestation •

This is the condition of being pregnant and usually refers to the number of weeks of pregnancy based on the first day of the last normal menstrual period or on ultrasound dating of the pregnancy.

Gravida

• The number of times the mother has been pregnant regardless of outcome

Primigravida

• A woman who is pregnant for the first time

Multigravida • A woman who is pregnant for at least the second time of has been pregnant two or more times.

Parity

• Number of pregnancies that reach viability

Multipara

• A woman who experienced two or more pregnancies which where more than 20 weeks age of gestation.

Nulligravida • A woman who has zero pregnancies (never been pregnant).

Nullipara • A woman who has experienced pregnancies but never reached viability

Quickening • Maternal perception of the first fetal movements. • Usually occurs about 20 week in primigravida

BRAXTON HICKS CONTRACTION • PAINLESS PALPABLE CONTRACTIONS OCCURING AT IRREGULAR INTERVAL AND FELT BY THE MOTHER AS SENSATION OF TIGHTNESS OVER HER ABDOMEN. • BEGIN AS EARLY AS 8TH WEEKS AND TEND TO BECOME STRONGER AS PREGNANCY ADVANCES.

Chloasma

• The mask of pregnancy caused by a change in skin pigmentation

Linea Nigra

• The pigmentation of the line dividing the abdomen into left and right halves

Internal Examination • • • •

Presentation Effacement Cervical dilatation Station

Effacement

• Thinning and shortening of the cervix that occurs just before birth

Station • The relationship of the presenting part to an imaginary line between the ischial spines of the pelvis

THE HEAD OF THE FETUS IS THE MOST IMPT PART OF ITS BODY BECAUSE: • It is the largest part of the fetal body so it is the part that would likely encounter difficulty during delivery • It is often the presenting part so its measurement, structure , position and presentation are impt factor to consider when determining labor outcome • Least compressible of all fetal parts

LONGITUDINAL LIE • The long axis of the fetus is parallel to the long axis of the mother, meaning THE FETUS IS LYING LENGTHWISE IN THE MOTHER’S ABDOMEN.

TRANSVERSE AXIS • The long axis of the fetus is at right angle to the long axis of the mother, meaning, THE FETUS IS LYING CROSSWISE IN THE MOTHERS ABDOMEN.

OBLIQUE LIE • The fetus assuming this lie usually rotates to transverse or longitudinal lie in the course of labor.

DIAGNOSIS OF PREGNANCY  PRESUMPTIVE SIGNS  PROBABLE SIGNS  POSITIVE SIGNS  DANGER SIGNS

PRESUMPTIVE SIGNS & SYMPTOMS OF PREGNANCY: • • • • • • • •

M – MORNING SICKNESS A- AMENORRHEA C-CHANGE IN BREAST F- FATIQUE L-LASSITUDE (fatigue) U-URINARY FREQUENCY Q-QUICKENING S-SKIN CHANGES

PROBABLE SIGNS: • • • • • • • •

C – CHADWICKS H – HEGAR U- UTERINE ENLARGEMENT P- POSITIVE PREGNANCY TEST B – BALLOTEMENT O-OUTLINING OF FETAL BODY G- GOODELLS S- SOUFFLE CONTRACTION AND BRAXTON HICKS

DANGER SIGNS (1) Pelvic complaints

•

Vaginal bleeding – Which could signify spontaneous abortion, placenta previa, or abruptio placenta • Vaginal leakage of fluid – Which could signify rupture of membranes

DANGER SIGNS (2) Abdominal complaints • Epigastric pain – Occurs in women who have severe preeclampsia • Uterine cramping – Occur in women undergoing preterm labor

DANGER SIGNS (2) Abdominal complaints • Decreased fetal movements – Occurs when the fetus is in jeopardy • Persistent vomiting – In cases of hyperemesis gravidarum

DANGER SIGNS (3) Swelling • Seen on the fingers or face • Occurs in women who have severe preeclampsia

DANGER SIGNS (4) Cerebral disturbances • Dizziness • Mental confusion • Visual disturbances

DANGER SIGNS (4) Cerebral disturbances • Persistent headache • Occurs in women who have severe preeclampsia

DANGER SIGNS (5) Urinary complaints • Painful urination • Decreased urine output • May signify cystitis or pyelonephritis

DANGER SIGNS (6) Chills or fever • Occur in women who have pyelonephritis or chorioamnionitis

Interventions • PRENATAL CARE • A. Time Frame 1. First Visit: – may be made as soon as woman suspects she is pregnant; frequently after first missed period.

Interventions 2. Subsequent Visits: – Every month until the 8th month, every 2 weeks during the 8th month, and weekly during the 9th month; more frequent visits are scheduled if problems arise.

– < 32 weeks AOG - every month – 32 – 36 weeks AOG - every 2 weeks – >36 weeks AOG - every week

Physiologic Changes in Pregnancy A. Alimentary tract 2. Appetite  Pica  dietary cravings or aversion for nonnutritional substances

1. Mouth  Ptyalism  usually associated with nausea of pregnancy

A. Alimentary Tract 3. Stomach  tone and motility  smooth muscle – relaxing effect of progesterone  GE junction sphincter  leads to acid reflux causing heartburn  PUD  increased gastric mucous secretion

Alimentary Tract 5. Colon  motility  constipation  hemorrhoidal veins dilate  hemorrhoids

6. Gallbladder  emptying time  biliary cholesterol saturation  inc risk of gallstone formation

Alimentary Tract 7. Nausea and vomiting  onset: 4 – 8 weeks AOG lasting 14 – 16 weeks  caused by stomach tone and hCG  supportive treatment  frequent small meals

Respiratory system  TV, but all lung volumes decrease  Vital Capacity, but other lung capacities remain unchanged  “dyspnea of pregnancy”  Oxygen consumption

Skin 1. Vascular changes 

Estrogen levels

 Spider angioma  face, thorax, and arms  Palmar erythema  skin blood flow to the hands

1. Striae gravidarum  normal stretching of the skin (pink purple  silvery white) 2. Pigmentation changes  MSH stimulated by Estrogen and Progesterone

Urinary system 1. Kidney 

size of renal pelvis  physiologic hydronephrosis

1. Ureter  Dilates  hydroureter and urinary stasis

1. Consequence 

risk pyelonephritis

Urinary system GFR by 50% creatinine clearance creatinine and urea by 25% Glucosuria  common in normal pregnancy  risk of UTI Proteinuria NOT normal in pregnancy

Cardiovascular system By 20 weeks AOG CO by 35% CO is dependent on maternal position Optimal CO  left lateral position (the IVC is not compressed by the uterus)

Hematologic changes Plasma volume 50% by term RBC mass 30% by term Physiologic anemia  hemoglobin value that results from a smaller in RBC than in plasma volume

Hematologic changes  Pregnancy is a hypercoagulable state  clotting factors  Venous stasis thromboembolism  Vessel wall injury

Endocrine and Metabolic changes size of the thyroid gland Thyroid-binding globulin (TBG)  from estrogen stimulation, T3 and T4 Note: Active unbound hormone forms remain unchanged (free T3 andT4)

Musculo – skeletal changes  Relaxin  increased ligamental laxity, contributing to back pain  Shift in posture with exaggerated lumbar lordosis

• CAUSES OF BLEEDING DURING PREGNANCY

ABORTION • The expulsion or removal of an embryo or fetus from the uterus at a stage of pregnancy when it is incapable of independent survival. • Less than 20 weeks age of gestation • Embryo weighs less than 500 grams

TYPES Missed Abortion Threatened Abortion Inevitable Abortion Incomplete Abortion Complete Abortion Septic Abortion

MISSED ABORTION • Diagnosed if there is sonographic evidence of a nonviable pregnancy without bleeding or cramping

MISSED ABORTION •

Abnormal sonographic findings – Gestation sac that is collapsing or irregularly shaped – Yolk sac that is not seen – Embryo that is absent or amorphous – Cardiac activity that is absent

MISSED ABORTION • Management – Scheduled suction dilatation and curettage (D&C)

THREATENED ABORTION

• Minimal bleeding is the key element

THREATENED ABORTION •

Diagnostic criteria – Minimal bleeding with or without mild cramping – Closed internal cervical os – Normal sonographic findings

THREATENED ABORTION •

Management Expectant observation Bed rest SAVE ALL PADS NO COITUS UPTO 2 WEEKS AFTER BLEEDING STOPPED – Tocolytic agents – – – –

Tocolytic Agents B – Adrenergic Agonist Magnesium Sulfate Prostaglandin Synthesis Inhibitors Calcium Channel Blockers

INEVITALBE ABORTION • Indicates that pregnancy is doomed to end shortly • Progressive cervical dilatation without the passage of tissue

INEVITALBE ABORTION •

diagnostic criteria heavy, profuse bleeding severe cramping dilated internal cervical os ( - ) BOW assessment of blood loss assessment of internal cervical os

INEVITALBE ABORTION •

Management – – – –

HOSPITALIZATION D AND C OXYTOCIN AFTER D AND C EMOTIONAL SUPPORT

INCOMPLETE ABORTION • Internal cervical os is open • The patient has passed some tissue

INCOMPLETE ABORTION • diagnostic criteria ability to pass ring forceps through the internal cervical os passing of the tissue

INCOMPLETE ABORTION •

Management Monitor vital signs for tachycardia and hypotension Monitor I and O. Oliguria is a sign of decreased renal perfusion which occurs with shock Emergency suction D&C

COMPLETED ABORTION • Diagnosed if the patient has passed tissue • But now bleeding and cramping is only minimal

COMPLETED ABORTION •

diagnostic criteria historical finding of bleeding, cramping, and passage of tissue dilated internal cervical os minimal current bleeding sonographic findings of empty uterus

COMPLETED ABORTION • Management supportive

SEPTIC ABORTION Abortion with concomitant sepsis Usually happens in induced abortion (+) fever

EXERCISE

• Complete the following table.

TYPES

MISSED THREATENED IMMINENT INEVITABLE INCOMPLETE COMPLETE SEPTIC

VariabiliBleeding ty

Cervix

BOW

Tissue Febrile? passed?

TYPES

VariabilitBleeding y

Cervix

BOW

Tissue Febrile? passed?

MISSED

NO

NO

CLOSED

( -)

NO

NO

THREATENED

YES

YES

CLOSED

(+)

NO

NO

IMMINENT

VARIAB LE

YES

OPEN

(+)

VARIAB LE

NO

INEVITABLE VARIAB LE

YES

OPEN

( -)

VARIAB LE

NO

INCOMPLETE

N/A

YES

OPEN

( -)

YES

NO

COMPLETE

N/A

YES

OPEN

( -)

YES

NO

SEPTIC

N/A

VARIAB LE

OPEN

( -)

YES

YES

INDUCED ABORTION The deliberate termination of a pregnancy in a manner that ensures the death of the embryo or fetus Ethical issues

General Risks of Abortion • Uterine perforation  intrauterine instrumentations • Cervical trauma  excessively rapid cervical dilatation  resulting in incompetent cervix

LAMINARIA  hydrophilic rods which absorb cervical fluid and to enlarge to many times their original volume, thus dilating the cervix

General Risks of Abortion • Bleeding and hemorrhage  occur from the placental site before uterine contractions can close the vessel • Infection  from normal genital flora

Medical methods of induced abortion • MIFEPRISTONE (RU486)  a progesterone antagonist  an oral preparation used with a prostaglandin agent to induced contractions  when administered before 10 weeks AOG, 95% of pregnancies are interrupted

Medical methods of induced abortion • METHOTREXATE  a folic acid antimetabolite  has similar action to mifepristone

Ectopic Pregnancy • Occurs when the site of implantation is outside of the womb. • It can occur in several places Ovary Abdomen Cornua Cervix Fimbria Fallopian tube

Sites of Ectopic Pregnancy

Risk Factors • Pelvic Inflammatory Disease – the most common risk factor for ectopic pregnancy – 8x increased risk – infection causes scar tissue adhesions in the tube and may damage the cilia.

• Previous ectopic pregnancy – the chances of another one in the same Fallopian tube and in the other tube are increased. – 5x increased risk

Risk Factors • • • • •

Tubal ligation in the past 2 years Previous tubal surgery Intrauterine device in place Prolonged infertility Diethystilbestrol (DES) exposure in utero

Clinical Findings Clinical Triad (3As) • Amenorrhea • Abdominal pain • Abnormal vaginal bleeding

• Signs and symptoms • Before Rupture  abdominal pain & tenderness  amenorrhea  abnormal vaginal bleeding.  palpable pelvic mass • Rupture  exacerbation of pain • After Rupture  faintness / dizziness  referred shoulder pain  signs of shock

Diagnosis Pelvic exam Blood tests Ultrasound Culdocentesis Laparoscopy

Medical Management METHOTREXATE  A folic acid antagonist that is metabolized in the liver and excreted in the kidney  This makes the ectopic pregnancy shrink away by stopping the cells dividing

Surgical Management Salpingectomy Salpingotomy Salpingostomy

INCOMPETENT CERVIX  presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation

ETIOLOGY  Hx of tears or lacerations in cervix during childbirth  Forceful D&C  Exposure of mother to diethylstilbestrol (DES)  Short cervix  Uterine abnormalities  Hx of early cervical dilation in previous pregnancies  Cervical surgery

Signs and symptoms  Pressure in the lower abdomen or vaginal pressure  Unusual urinary frequency  Vaginal discharge (with or without blood)  Sensation of a lump in the vagina

Diagnosis The most accurate diagnosis is a retrospective one History of painless midtrimester cervical dilatation resulting in expulsion of a non-viable fetus

Medical Treatment Cerclage  Shirodkar method  McDonald procedure

McDonald cerclage

The Shirodkar

Gestational Trophoblastic Neoplasia (GTN) • Hydatidiform moles (H – mole) Benign Consists of a nonviable embryo which implants and proliferates within the uterus Presence of multiple grape – like vesicles filling the uterus

• Gestational trophoblastic tumor (GTT) Malignant

Complete hydatidiform mole

The grape-like villi of a hydatidiform mole are seen here. With molar pregnancy, the uterus becomes large for dates as the pregnancy progresses, but no fetus is present

Etiology  chromosomal problems  poor nutrition  problem w/ the ovaries or the uterus  placental fragments following miscarriage or childbirth

Risk Factors  Maternal age extremes (<20, >40 years old)  Diet (low in beta carotene, folate deficiency)  Large uterus

Signs and symptoms  Bleeding during the first half of pregnancy (usually prior to 16 weeks AOG)  Severe hyperemesis  Abnormal growth in the size of the uterus for the stage of the pregnancy  Passage of vesicles, ( - ) FHT  Symptoms of hyperthyroidism

Diagnosis   HCG levels  Histologic examination  Ultrasonography  (+) grapelike clusters  snowstorm pattern  Doppler ultrasonography  (−) fetal heart tones

Surgical Treatment Dilation and curettage (D & C) with suction evacuation Hysterectomy - ovaries usually are not removed

Medical Treatment  Chemotherapeutic agents  Weekly B-hCG titers until they are negative for 3 weeks  Monthly titers until they are negative for 12 months

Abruptio Placenta • Premature partial or complete separation of normally implanted placenta. • The placenta appear to have been implanted correctly, suddenly, however, it begins to separate and bleeding results.

Abruptio Placenta (TYPES)

Partial Abruptio Placenta Marginal Abruptio Placenta Complete Abruptio Placenta

TYPES

Partial

Marginal

Complete

Risk factors • • • • • •

High parity Chronic hypertensive disease Hypertension of pregnancy Direct traumas Vasoconstriction from cocaine use Cigarette smoking

Clinical manifestations • Sharp, stabbing pain high in the uterine fundus • Heavy bleeding • Signs of shock • The uterus becomes tense and rigid to touch

Diagnosis • Best made clinically • Ultrasound often fails to detect retroplacental bleeding, causing false negative diagnoses.

Hemorrhage

occurs into the decidua basalis, separating part of the placenta from the uterus. Blood from forming hematoma may remain retroplacental (concealed) or may progress to the edge of the placenta.

Therapeutic Management • Fluid replacement and oxygen by mask to limit fetal anoxia. • Monitor fetal heart sounds externally and record maternal vital signs every 5-15 minutes.

Therapeutic Management • Keep the woman in a lateral, not supine position • Do not give an enema to the woman with a diagnosed or suspected placental separation.

Intervention • Blood and fluids replacement • Cesarean birth

NEXT…

• Placenta Previa…

Placenta Previa • Abnormal implantation of placenta in lower uterine segment

Risk factors • Increased parity • Advanced maternal age • Past caesarian births • Past uterine curettage • Multiple gestations

Degrees of Placenta Previa • Partial – Placenta partially covers the internal cervical os. • Complete – Placenta totally covers the cervical os (caesarian birth necessary) • Low-lying or marginal – Placenta encroaches on margin of internal cervical os.

Degrees of Placenta Previa

Normal

Low - lying

Partial

Total

Clinical Manifestations • Painless, bright red, vaginal bleeding in the third trimester (often begins during the seventh month) • Soft uterus • Manifestations of hemorrhage, shock

DIAGNOSIS

• Ultrasound

The

passive lower uterine segment stretches and thins, which alters the lower uterine segment implantation site of the placenta.

The

venous sinuses are exposed as the placental anchoring villi are avulsed from the decidua

Timing

of the first bleed is determined by:

◦ how early in pregnancy the lower uterine begins to form ◦ how low the placenta is implanted The extent of the first bleed

is variable, and each successive bleed tends to be heavier

Therapeutic Management • Place woman immediately on bed rest in a side-lying position. • Inspect the woman’s perineum for bleeding. • Never attempt a pelvic exam with painless bleeding late in pregnancy • Obtain baseline vital signs to determine whether symptoms of shock are present.

Therapeutic Management • Vaginal examinations (actual investigation of dilation) to determine whether placenta previa exists are done in an operating room • Have oxygen equipment available in case the fetal heart sounds indicate fetal distress

Intervention • Blood and Fluid replacement • Caesarian birth if placental placement prevents vaginal birth of fetus.

Abruptio Placenta VS Placenta Previa

CLINICAL CHARACTERISTICS Clinical Finding Bleeding Characteristics

Suggestive of Placenta Previa

Suggestive of Abruptio Placentae



Onset

May be gradual, Often abrupt, progressive unexpected



How evident Always external May be either external or concealed.



Color

Bright red

Dark

CLINICAL CHARACTERISTICS Clinical Finding

Suggestive of Placenta Previa

Fetal Status 

FHT

Usually present



Engagement Absent

Suggestive of Abruptio Placentae May be absent (if fetal demise) May be present

(placenta obstruct) 

Presentation Often Unaffected by malpresentation bleeding

CLINICAL CHARACTERISTICS Clinical Findind Uterine Characteristics

Suggestive of Placenta Previa

Suggestive of Abruptio Placentae



Pain

Painless unless labor

Intense and steady



Tenderness

Absent

Present



Tone and Shape

Soft and relax, Normal

Firm to stony hard, May enlarge and change shape

• OBSTETRIC COMPLICATIONS and • MEDICAL COMPLICATION

RH INCOMPATIBILITY OR ISOIMMUNIZATION A

condition which develops when a pregnant woman has an Rh-negative blood type and the fetus she carries has Rh-positive blood type.

Requirements for maternal RBC Isoimmunization FETUS

 antigen – positive RBC MOTHER  antigen – negative RBC Sufficient fetal RBC must have gain access to the maternal circulation  Mother must have the immunogenic capacity to produce antibodies against fetal RBC antigen

MANAGEMENT: Explain about Rh incompatibility Give Rh D immune globulin (RHIG) at 28 weeks during pregnancy and 72 hours after the delivery Offer support to the client.

A complication of pregnancy because a woman’s body must adjust to the effects of more than one fetus The higher the woman’s parity and age the more likely she is to have a multiple gestation

The use of IN VITRO FERTILIZATION The use of fertility drugs clomiphine citrate gonadotropin

Increase in the size of the uterus at a rate faster than the normal Elevated alpha-fetoprotein In quickening – flurries of action at different portion of the woman’s abdomen rather than at one consistent spot Multiple sets of fetal heart sounds may be heard upon auscultating the abdomen In sonogram, multiple gestation sacs

Maternal     

Pregnancy Induced Hypertension Hydramnios Placenta previa Anemia Post-partum bleeding

Fetal  Low birth babies  Birth defects  Congenital anomalies in twins

NSD CS

/ VSD

Pregnancy Induce Hypertension (PIH) • also called “Toxemia” • Refers to a potentially severe and even fatal elevation of blood pressure that occurs during pregnancy. • The cause is unknown (idiopathic) • A condition in which vasospasm occurs during pregnancy.

SPECTRUM ✦ Mild Preeclampsia BP >= 140/90 mmHg Proteinuria of 1 – 2 + on dipstick or >= 300 mg in 24 hour urine collection ✦ Severe Preeclampsia BP >= 160/110 mmHg Proteinuria of >= 3 – 4 + on dipstick or >= 5g in 24 hour urine collection ✦ Eclampsia

PIH ✦ occurs only in pregnant women beyond 20 weeks’ gestation ✦ About 5% of pregnant women develop preeclampsia (toxemia of pregnancy

Risk Factors ✦ Nulliparity (most common risk factor) ✦ Age extremes (<20, >40 years old) ✦ Multiple gestation ✦ Diabetes Mellitus ✦ Chronic hypertension

Assessment Findings  Rapid weight gain  Over 2 lbs/wk in the 2nd trimester  1 lb/wk in 3rd trimester  Due to abnormal tissue fluid retention

Assessment Findings  Swelling of face or fingers  Hands – ask the women if she notice that her rings are tight  Face – difficulty opening eyes in the morning due to edema of the eyelids

Assessment Findings  Dimness or blurring of vision and severe, continuous headache  This signal cerebral edema or acute hypertension

Assessment Findings Severe epigastric pain, nausea and vomiting due to abdominal edema or ischemia to the pancreas and liver. Feeling shortness of breath due to pulmonary edema.

Eclampsia • Tonic – clonic seizure • Not good candidate for surgery, the preferred method for birth then is vaginal

HELLP syndrome  Hemolysis  Elevated levels of liver enzymes  liver damage  Low platelet count  making blood less able to clot and increasing the risk of bleeding during and after labor.

Nursing Diagnosis: • Ineffective tissue perfusion related to vasoconstriction of blood vessels • Deficient fluid volume related to fluid loss to subcutaneous tissues. • Risk for fetal injury related to reduced placental perfusion secondary to vasospasm. • Social isolation related to prescribed bed rest.

Nursing Interventions Monitor Fetal Well-Being Support a Nutritious Diet  moderate to high in protein and moderate in sodium to compensate for the protein she is losing in the urine.

Pharmacologic Treatment ✦ HYDRALAZINE

✦ direct arteriolar vasodilator ✦ lowers the blood pressure ✦LABETOLOL ✦ non selective B blocker ✦ lowers the blood pressure

Magnesium Sulfate ✦ Prevention of convulsion ✦ Loading dose of 5g IV over 20 minutes ✦ Maintenance infusion at 2g/hr ✦ WOF clinical evidence of magnesium toxicity ✦ Absence of toxicity is ensured as long as DTR are obtainable

Magnesium Sulfate DOSE 5

– 8 mg/dL

EFFECT Therapeutic

10

mg/dL

Loss

15

mg/dL

Respiratory

25

mg/dL

level

of DTR

paralysis Cardiac arrest

✦What is the antidote for Magnesium toxicity?

What is the antidote for Magnesium toxicity? ✦CALCIUM GLUCONATE ✦ 1g IV push

GRAVIDO CARDIACS  The danger of pregnancy is a

woman with cardiac disease occurs primarily due to the increase in circulatory volume.  Weeks 28-32, most dangerous time for woman, just after the blood volume peaks.

Structural Classification  Acquired Heart Disease  MS, MI

 Congenital Heart Disease  ASD, TOF  Peripartum

Cardiomyopathy

Assessment Findings: Severe or progressive dyspnea Paroxysmal nocturnal dyspnea Progressive orthopnea Syncope with exertion Chest pain related to effort or emotion

PRINCIPLES of Prenatal Mgt Fluid retention should be avoided Strenuous activity should be avoided Anemia should be avoided

PRINCIPLES of Intrapartum Mgt Reassurance and sedation Use of epidural analgesia Left Lateral position Forceps delivery

PRINCIPLES of Postpartum Mgt Close observation for volume overload

A condition of abnormal

glucose metabolism that arises during pregnancy

 There is progressive

resistance to the efforts of insulin

Diabetogenic effect of human

placental lactogen (hPL)

 Placental insulinase, elevated

free cortisol, and progesterone  glucose intolerance

Risk Factors: Obesity Age over 25 years old History of large babies (10 lbs. or more)  History of unexplained fetal or perinatal loss  History of congenital anomalies in previous pregnancies  Family history of diabetes   

1 hour OGTT 3 hour OGTT Non valid screening include: urine glucose values glycosylated hemoglobin

3 hour OGTT  Two or more values equal or

greater than the following are necessary for positive diagnosis: Fasting: 95 mg/dL 1 – hour: 180mg/dL 2 – hour: 155 mg/dL 3 – hour: 140 mg/dL

 PNCU  Dietary management  Management of maternal

glycemic control  central goal  SQ long acting human insulin  OHA  contraindicated

 No need to induce labor

before 40 weeks AOG  Macrosomic risk  Risk of shoulder dystocia  Blood glucose level should be monitored

 Hypoglycemia  result of

hyperinsulinemia from in utero hyperglycemia  Hypocalcemia  immature parathyroid hormone function  Hyperbilirubinemia  liver enzyme immaturity and inc breakdown of RBC

 Respiratory distress 

delayed pulmonary surfactant production Polycythemia  increased erythropoietin due to relative intrauterine hypoxia

 Postpartum hemorrhage

resulting from uterine atony  Evaluate for overt diabetes

Prenatal Care and Assessment

LEOPOLDS MANEUVER • Systematic method of observation and palpation to determine fetal position • Empty the bladder, lie in supine position with her knees flexed so abdominal muscles are relaxed • Warm hands to avoid contraction of the abdominal muscles • Gentle but firm touch

LEOPOLDS MANEUVER • FIRST MANEUVER: FUNDAL GRIP • SECOND MANEUVER: UMBILICAL GRIP • THIRD MANEUVER: PAWLIKS GRIP • FOURTH MANEUVER: PELVIC GRIP

Leopold’s Maneuver  1st  What fetal part is in the fundus? LPr  2nd  On which side are the fetal back or small parts located? Po  3rd  To what degree has the presenting part descended into the pelvis? S  4th  On which side is the cephalic prominence located? A

Leopold’s Maneuver

Utero-placental Orientation Fetal Lie Fetal Presentation Fetal Position Fetal Station Fetal Attitude

FETAL LIE – Relationship of the fetus to the long axis of mother

FETAL LIE •

Normal Lie: Longitudinal – Fetus long axis in line with mother long axis

FETAL LIE •

Abnormal lie – Transverse Lie – Oblique Lie (unstable lie)

FETAL PRESENTATION •

Presentation: Breech (Head is not presenting part) – – –

Occurs in 25% of pregnancies at 30 weeks Abnormal after 32 weeks Types of Breech Presentation

FETAL PRESENTATION •

FRANK BREECH PRESENTATION – –

Thighs are flexed on the abdomen So that the legs are extended over the anterior surface of the body

FETAL PRESENTATION • COMPLETE BREECH – Thighs are flexed on the abdomen – And the legs are flexed upon the thigh

FETAL PRESENTATION • INCOMPLETE BREECH – One or both thighs are extended – So that the feet and legs are below the level of the buttocks

FETAL PRESENTATION

FETAL PRESENTATION •

Presentation: Cephalic (Head is presenting part)

FETAL POSITION Relationship between a reference point on the presenting fetal part and maternal bony pelvis Position of the Fetal denominator to mother's pelvis Fetal Denominator: Occiput of Vertex

FETAL POSITION

FETAL POSITION

STATION (Fetal Descent) •

Definition: Fetal Station The degree of descent of the presenting part through the birth canal, expressed in cm. The presenting part is above or below the maternal ischial spine.

STATION (Fetal Descent) •

Zero Station Notation (presenting part level) Presenting part in relation to ischial spines Reported in centimeters from ischial spines Negative numbers are behind the ischial spines

STATION (Fetal Descent) •

Engagement Refers to presenting part meeting pelvic floor Occurs at 0 station

FETAL ATTITUDE • Degree of flexion or extension of fetal head • Most common subcategory: Vertex – Complete flexion – Chin against the chest – Suboccipito-bregmatic

FETAL ATTITUDE Normal Attitude: Fetus is in full flexion Every fetal joint is flexed Smallest fetal head diameter: Suboccipitobregmatic Diameter is 9.5 cm.

FETAL ATTITUDE •

Sinciput Presentation – –

Occipito-frontal Diameter is 12. 5 cm

FETAL ATTITUDE Abnormal presentations: Extended Attitude General • Abnormal Attitude: Fetal head is extended • Results in largest head diameter: Occipito-mental (Brow) • Diameter is 13.5 cm. • May results in Failure to progress

FETAL ATTITUDE •

Face Presentation – – –

Submento-bregmatic Diameter is 9.5 cm Fetal head is hyper extended

CONTRACTION • Frequency • Duration • Interval

Labor and Delivery

TRUE versus FALSE LABOR TRUE FALSE CONTRACTION • Regular • Irregular • Increasing • No change in frequency, duration, frequency, and intensity duration, and intensity • Shortening of interval DISCOMFORT

• Pain begins in • Pain focused back and radiates to in the abdomen abdomen

TRUE versus FALSE LABOR TRUE

FALSE

REST / • Contraction does • Contraction ACTIVITY not decrease with rest may lessen with or activity activity or rest CERVIX

• Progressive effacement and dilation of cervix

• Cervix changes do not occur yet

Cardinal Movements of Labor  Engagement  Descent  Flexion  Internal Rotation  Extension  External Rotation  Expulsion

Stages of Labor First Stage of Labor Second Stage of Labor Third Stage of Labor Fourth Stage of Labor

First stage of labor • Begins with onset of uterine contraction until full cervical dilatation • Contains the latent and active phase • Duration of cervical dilatation varies (≥1.5 cm/hr in multiparas and ≥ 1.2 cm/hr in primiparas)

Phases of the First Stage of Labor: 1. Latent 2. Active 3. Transitional

Latent phase  Early part in labor characterized by:  Cervical dilatation of about 2-3 cm.  Mild, regular uterine contractions  Intervals of 5-10 minutes apart  Duration of 30 seconds  Mother becomes talkative, alert, excited but in control

Active phase Characterized by:  Cervical dilatation of 4-8 cm.  Frequency of 3-5 minutes  Rapid increase in duration of 45-60 seconds  Intensity becomes moderate  Mother less talkative, more anxious, restless and fears losing control

Transition phase

Nursing Care and Management during the First Stage of Labor • • • • • •

Admit the patient Check the vital signs and FHT Physical examinations Perineal preparation Monitor and assess uterine contraction Avoid giving food

Nursing Care and Management during the First Stage of Labor • Encourage the parturient to void at least within 2 hours. • Woman during labor may ambulate • Monitor danger signs • Comfort measures • Transfer to DR table

Second stage of labor • Begins with complete cervical dilatation and ends with the delivery of the baby • Duration for multiparas and primiparas are 30 and 60 minutes respectively

Mechanisms of Labor • Refers to the changes of position of the fetus will undergo as it pass the birth canal • D  F  IR  Ext  ER  Exp

Nursing care and Management during the Second Stage of Labor • Proper positioning • Cleanse vulva thoroughly with soap and water or any surgical antiseptic • Instruct the parturient to take a deep breath as soon as the next uterine contraction begins and with her breath hold, to exert downward pressure as though she were straining a stool.

Nursing care and Management during the Second Stage of Labor • Upon the delivery of the baby, milk the cord towards the infant, clamp an inch apart and cut in between. • Clamping the cord should be done when pulsations had stopped to allow the passage of blood from the placenta to the cord and to the fetus.

Nursing care and Management during the Second Stage of Labor • Show the baby to the mother (eye to eye contact to facilitate bonding). • Inform the mother about the sex of the baby. • Hand in the baby to the assisting nurse (in the OR circulating nurse) so that the ID bond is immediately put on the baby.

Third stage of labor

• Begins with delivery of the baby and ends with the delivery of the placenta

Phases of the Third Stage of Labor • Placental Separation Phase  caused primarily by the disproportion of the placenta from the placental implantation site • Placental Expulsion Phase

Signs of placental separation:  Calkin’s sign.  discoid  firm and globular in shape  Sudden gush of blood from the introitus Apparent lengthening of the umbilical cord as the placenta get closer to the introitus.  As the umbilical cord slowly extends out, it can be winded to the clamp or forceps and this is called as the Brandt Andrews Method.

Type of Placental Mechanisms: Schultze mechanism 80% of all deliveries Begins at the center

Duncan’s mechanism 20% of all deliveries Begins at the edges / periphery

Nursing Care and Management during the Third Stage of Labor • Careful management of placental expulsion • Watch for the signs of placental separation • Deliver the placenta with Brandt Andrews method • Note the time the placenta is delivered

Nursing Care and Management during the Third Stage of Labor • Check for the completeness of the placenta • Check and evaluate the blood pressure • Administer oxytocin medicine after the placenta has been completely expelled to prevent and control hemorrhage • Inspect perineum, vagina and cervix for laceration, extension of the episiotomy or hematomas.

Types of Laceration: First degree

 vaginal mucous membranes and the skin of the perineum

Second degree  levator ani and perineal body

Third degree  entire perineum and external sphincter of the rectum

Fourth degree  entire perineum, rectal sphincter and mucous membrane of the rectum

Episiotomy

Nursing Care and Management during the Third Stage of Labor Carefully examine the uterine cavity manually Assist the physician in episiorrhaphy Note down vaginal packing if any: the number of vaginal pack in placed the time of removal (endorse) at least within 2448 hours.

Cleanse the vulva with sterile water.

Nursing Care and Management during the Third Stage of Labor • Apply perineal pad (application should be from front to back). • Lower legs of the woman simultaneously from the stirrup to avoid injury to the uterine ligaments. • Change the woman’s gown. • Transfer the newly delivered mother to the ward.

Fourth stage of labor • Begins with the delivery of the placenta and ends after 1 – 4 hours. • Watch out for bleeding • Keep uterus contracted

Nursing Care and Management in the Fourth Stage of Labor • Check the fundus every 15 minutes for its contractility. • What is the FIRST nursing action for a soft and boggy uterus? • Check lochia every 15 minutes in conjunction with assessment of the fundus.

• Will you report a heavy flow with a uterus well contracted?

Nursing Care and Management in the Fourth Stage of Labor • Check perineum and episiotomy • Check BP every 15 minutes for the first hour until stable • Immediate medical intervention will be necessary if any of the following occur:

Marked bleeding persists Complaints of lightheaded and blurring of vision. Ashen color / pallor Cold clammy skin Exhibits air hunger Restlessness Decreased BP Increased PR and RR Dyspnea

Emergency management/interventions: Check the fundus of the uterus for firmness Increase IV flow rate and add oxytocin as per doctor’s order Elevate the foot part of the bed to allow the fast return of the blood to the upper part of the body. Administer oxygen Call for help

Puerperium

POSTPARTUM • The period of time, usually six weeks, in which the mother’s body experiences anatomic and physiologic changes that reverses the body’s adaptation to pregnancy. • May also be called INVOLUTION.

POSTPARTUM • Begins with the delivery of the placenta • Ends when all body systems are returned to, or nearly to, their prepregnancy state.

UTERUS A rapid reversal in size At the level of the UMBILICUS immediately post delivery The uterus regresses approximately 1 fingerbreadth (1cm) per day.

Endometrial regeneration • LOCHIA • The debris discharged by the uterus following delivery

LOCHIA RUBRA • Dark red in color • Normal 1 – 3 days after delivery • Discharge may contain small clots, but large clots are abnormal and may indicate hemorrhage • Also contain cellular debris from decidua

LOCHIA SEROSA • Brownish to pinkish in color • Lasts from 4th to the 10th day • Contain mostly serum, some blood, and tissue debris

LOCHIA ALBA • Cream colored discharged • Begins around the 10th day and last for a week or two • Mostly leukocytes, with decidua, and mucus

CERVIX Flabby immediately after delivery; closes slowly Admits one fingertip by the end of one week after delivery

VAGINA Edematous after delivery May have small lacerations Smooth-walled for 3 – 4 weeks, then rugae reappear

Abdominal Wall / Skin May need six weeks to reestablish good muscle tone. Stretch marks gradually disappear

Gastrointestinal System Mother usually hungry after delivery; good appetite is expected. May still experience constipation from the lack of muscle tone in the abdomen and perineal soreness.

BREASTS Initial secretion of colostrum, with increasing amounts of true breastmilk appearing between 48 – 96 hours. Milk “let – down” reflex caused by oxytocin from posterior pituitary released by sucking

Cardiovascular System Normal blood loss in vaginal delivery is 500 mL up to 1000 mL for cesarean section. Hematocrit normally returns to prepregnancy value within 4 – 6 weeks. Varicosities regress.

Urinary System Bladder base may be traumatized by labor and delivery Epidural anesthesia may decrease the sensation of fullness Perineal pain may inhibit voiding

Postpartum Emotional Responses • Postpartum blues  feelings of inadequacy, tearfulness, mood swings • Postpartum depression  feelings of despair, hopelessness, and anxiety • Postpartum psychosis  impairment of reality perception

Management • Reassurance • Rooming – in • No medications needed  Psychotherapy  Anti depressants  Anti psychotic medications Hospitalization required

PHASES OF PUERPERIUM TAKING-IN PHASE Time of reflection Prefers having a nurse administer to her (bath towel/night gown) and make decisions for her dependence Usually wants to talk about her pregnancy, especially about her pregnancy  labor and delivery

PHASES OF PUERPERIUM TAKING-HOLD PHASE Begins to initiate action Expressed interest in caring for her child Still feels insecure about her ability to care for her new child Needs positive reinforcement

PHASES OF PUERPERIUM LETTING-GO PHASE Finally defines her new role

Postpartum Hemorrhage • Excessive blood loss (>500 mL during the first 24 hours postpartum) after the delivery of an infant

CAUSES (PPH) Uterine atony  most common cause Genital laceration Retained placenta Uterine inversion

Diagnosis to Clinical Finding Management Plan Consider Uterine Atony Uterus is boggy and Uterine massage  Myometrial enlarged on Bimanual uterine dysfunction palpation compression  Pharmacologic Remove intrauterine  Uterine clots overdistension Administer oxytocin or methergin as ordered Undiagnosed Bleeding is present Assist in repairing tears involving from genital tract lacerations and episiotomy, cervix, lacerations extensions vagina, or uterus

Diagnosis to Clinical Finding Management Plan Consider Retained placental fragments

Placenta is not complete on examination

Manual uterine exploration Assist in uterine curettage

Uterine inversion

Uterus is not palpable on abdominal examination

Uterine replacement by elevation of vaginal fornices

FERTILITY CONTROL CONTRACEPTION Folk methods  Barrier and Spermicidal methods  Steroid hormone – based methods  IUD  Natural family planning 

FERTILITY CONTROL STERILIZATION

BTL Vasectomy 

FOLK METHOD Coitus interruptus Withdrawal of the penis from the vagina prior to ejaculation  Post coital douching Water, vinegar, or other products theoretically flush semen out of the vagina. (spermicidal properties) 

MALE CONDOM  A sheath

that is placed on the erect penis, preventing sperm deposition into the vagina  Most widely used mechanical contraception

MALE CONDOM

ADVANTAGES Inexpensive, readily available, and convenient Provide major protection against STD One size fits all 

DISADVANTAGES Reduction

of penile sensation Sexual spontaneity is lost Breakage is possible Male controlled

FEMALE CONDOM Contains

polyurethane pouch with two flexible rings Blind pouch end fits over the cervix, the open rests outside the vagina on the vulva

FEMALE CONDOM

FEMALE CONDOM

FEMALE CONDOM Advantages Provide protection against STD Female controlled  Disadvantages Bulkiness and awkwardness Relatively expensive 

VAGINAL DIAPHRAGM  A mechanical

and spermicidal barrier placed between the posterior vaginal fornix and the symphysis pubis  Containing spermicidal jelly against the external cervical os

VAGINAL DIAPHRAGM

VAGINAL DIAPHRAGM

VAGINAL DIAPHRAGM  Placement

may occur up to 2 hours before intercourse  Removal may be delayed for at least 6 hours after ejaculation  Prevent some STD  Female controlled

DISADVANTAGES Individual fitting Placement must occur before penile insertion Risk for infection (TSS) Reapplication of spermicide is required for repeated intercourse 

CERVICAL CAP 

A cup – like diaphragm that is placed tightly over the cervix without spermicide

CERVICAL CAP Insertion may occur from 30 minutes to 48 hours before intercourse  Left in place for a prolonged period  May prevent some STD  Female controlled 

DISADVANTAGE Individual

fitting is required Many women cannot feel their own cervix

VAGINAL CONTRACEPTIVE SPONGE 

A spermicide – impregnated polyurethane disk that is placed in the proximal vagina  Spermicide is released when the sponge is moistened and by the action of the intercourse

VAGINAL CONTRACEPTIVE SPONGE

VAGINAL CONTRACEPTIVE SPONGE  Insertion

may occur up to 24 hours before intercourse  Prevent some common STD  No need to re-apply spermicide for repeated intercourse  Female controlled  Size fits all

VAGINAL CONTRACEPTIVE SPONGE  The

sponge offers continuous protection for up to 24 hours after insertion, no matter how many times you have sex.  Left in place for at least 6 hours after intercourse 

Sold over-the-counter, without a prescription.

STEROID HORMONE – BASED METHOD ORAL AGENTS  Most commonly used methods of reversible contraception  Estrogen – progestin combination and Progestin only forms (minipill)

ADVANTAGES Contraceptive protection is continuous when taken correctly Contraceptive effect is readily reversible when the pills are discontinued Non-contraceptive health benefits 

Non – contraceptive health benefits incidence of dysmenorrhea decreased strength of menstrual contractions from prostaglandin suppression  incidence of benign breast disease decreased hormonal stimulation 

DISADVANTAGE  Must

be remembered and taken

daily  Intermenstrual bleeding and headaches  Weight gain may be noted  ACHES

INTRAMUSCULAR AGENT Depomedroxyprogesterone

acetate (DMPA) A progestin only formulation

DMPA IM injections (150mg) must be repeated every 3 months  Return of regular ovulation and normal menses may be delayed up to 12 months after discontinuation (usually 6 months)  Irregular bleeding, fluid retention, and weight gain 

SUBCUTANEOUS DEPOT METHODS

Norplant  L – norgestrel, which is contained in six Silastic capsules  Implanted beneath the upper arm skin  Effective within 24 hours of insertion if placed within 7 days of the onset of a woman's menstruation 

NORPLANT

NORPLANT Replaced only every 5 years SE: Irregular bleeding, fluid retention, weight gain 

IUD Progesterone

– impregnated

IUD Copper IUD Altered tubal motility for both sperm and egg transport

IUD

When

is an IUD inserted? A. Before menstruation B. During menstruation C. After menstruation D. Anytime the patient wants to

COMPLICATIONS Uterine

perforation Septic abortion PID

STERILIZATION Men  Vasectomy Women  Bilateral tubal ligation 

BTL

Minilaparotomy Laparoscopy 

MINILAPAROTOMY Defined as a laparotomy with an incision size smaller than 5 cm.  The operation can be performed through a suprapubic incision in the interval after pregnancy and through a subumbilical incision within the first 48 hours after delivery. 

LAPAROSCOPY Small incisions  Rapid access to the oviducts  Rapid recovery  Limited ability to inspect intraperitoneal organs 

VASECTOMY Objective

criteria for a successful vasectomy is AZOSPERMIA on a semen after 12 weeks or 20 ejaculations

VASECTOMY

VASECTOMY Make a small incisions, or cuts, in the skin of the scrotum, which has been numbed with a local anesthetic.  The vas is cut, and a small piece may be removed.  The doctor ties the cut ends and sews up the scrotal incision.  The entire procedure is then repeated on the other side. 

END

 Thank

you

POST TEST