MATERNAL AND CHILD NURSING

Assoc.Prof. Trinidad Silva-Ignacio, RM, RN, MAN

Faculty, University of Santo Tomas

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OVERVIEW OF THE REPRODUCTIVE SYSTEM

FEMALE
Breast
Dependent on the ovary for hormones
During menopause stop supply of hormones prone to cancer
Mons Pubis
Labia
Serves as a covering
Majora and minora
Minora - has erectile tissues (clitoris)
Clitoris
Anterior
Basis for catheterization
Avoid touching the clitoris when inserting the catheter may cause
convulsion in precclamptic patients
Fourchette
Posterior of minora
Stretch during delivery napupunit
Ritgens Maneuver
Perineal support
Protect the are from overstretching
Episiotomy
Prevents laceration
Cut during peak of contraction all the muscles are pulled up and
no muscles are cut
Should have anesthesia
How many strong contractions before episiotomy: 3
Mediolateral- hindi mag eextend to anus but many layers of tissues
are affected (Most common incision made)
Median- used for immediate delivery, may extend to anus
Vestibule
Triangle

Two important openings- 2 (urethra and vagina)

All openings- 6
Urethra
Urethral canal is very short at risk for infection
8-10 glasses of fluid / 50% should be plain water
UTI- increase fluids because no matter how much you do perineal
care, the proximity of the urethra to still predisposes it to infection
*Because of hormone change, pregnant is more at risk for infection
progesterone decreased renal threshold of sugar small amount
leak out sugar in vagina is good medium for bacterial growth
Vagina
Discharge: Fleshy smelling (Normal: 6-8 soaked napkin = 30ml of
blood)
More than 2000ml = shock
Organ for copulation
During birth passage no ruggae (less resistance) for easier
passage of the baby
Has ruggae (folds of muscles) which allow to stretch
Kegels exercise- to promote formation of ruggae
Pubo-coccygeal muscle
Contract the muscle to hold the urine, then release the muscle
Done as much as she wants
Hymen
Pag nastretch ang vagina, stretch din ang hymen

Imperforate

May lead to Pseudoamenorrhea/Cryptomenorrhea

Management is surgery; put to sleep to prevent damage to vagina
Rigid
Problem with intercourse
Management is surgery
Carunculae Myrtiformes - remnants of hymen after tearing
Doderleins bacillus
Normal flora
Bacteria that protects the woman from bacterial infection
Makes vagina acidic
Candida albicans (candidiasis) (moniliasis)- most common infection in
the woman
Yeast infection
Color (#1 assessment) - Yellowish creamy color
Consistency of discharge: thicker
Smell: no smell
Pruritus
Vaginal suppository (MICONAZOLE, MONISTAT)
Local effect only
Best time to insert the vaginal suppository: night time patient not
upright drug is dissolved in vagina
6 hours for drug to take effect
Should report MORE discharge; drug and infection (only 1 day)

Only needs a single dose

Effect on Baby: infection on babys MOUTH (Oral moniliasis)
Trichomonas vaginalis
SMELLY!!!!!!!!!
Greenish grayish frothy
Gonorrheal
Effect on baby: eyes
Chlamydial
Effect on baby: eyes
Cervical Mucus
From cervical glands - Spinbarkeitt
Endocervical gland in cervix
2 hormones that affects the cervix
Estrogen
Progesterone
Estrogen
Progesterone
Dilates the cervix
Closes the cervix
Released before ovulation
Released on the 16th day
14th day
Mucus is decreased in amount,
Mucus is watery, clear,
sticky, cloudy Spinnbarkheit: 3
stretchy Spinnbarkheit 6cm
12 cm
Safe Period
Unsafe period
Ph: 6
13th day of the 28th day
Hormone that protects the baby
cycle
Dec. progesterone (AP) = Inc.
For 3-5 days
oxytocin (PPG)
Ph: 8
Operculum
Mucus that plugs the cervix
More discharge formation of mucus plug
Protects the baby from possible entry of infection
Show- sign of cervical dilation
Cervical dilation- indication that the woman has started labor
Uterus
Estrogen- thickens the muscle (hypertrophy)
Progesterone- relaxes the uterus, maintains the pregnancy
Upper Segment(Fundus)
most active segment of the uterus
Muscles are found in all directions figure of 8
Upper central and posterior segment- best site for implantation of
placenta
Placenta previa- bigger placenta
Placenta obstruct the passage way
Bleeding from the placenta
Painless
Last trimester
Lower Segment
Passive segment
Longitudinal muscles
During contraction, same shape of uterus (globular shaped)
Physiologic retraction ring (normal)
Imaginary line that separates the upper and the lower segment of
the uterus during labor
Not seen but palpable
Pathologic retraction ring (Bandles ring)
There is an overstretching of the uterus
Visible separation of the upper and lower segment of the uterus
There is an obstruction of the babys passageway
Distended bladder
Make sure the patient voids every 2 hour intervals
Straight catheter
Cephalo-pelvic disproportion
CS
Perimetrium
Myometrium
Endometrium
1.5 cm thick due to influence of estrogen and progesterone (supplied
by the ovary) (release estrogen and progesterone simultaneously)
During pregnancy 6 cm thick
Protective mechanism of the hormones to maintain the lining for the
DECIDUA- endometrium during pregnancy
Estrogen and progesterone released at the same time
Hormones in the ovary are at rest, PLACENTA takes over supply of
hormones
3 months before the woman starts menstruating again
Decidua Basalis where placenta is attached; E and P maintain it
Zona basalis remains when decidua is shed; new endometrium for
next pregnancy
Decidua Vera
Decidua Capsularis
Lochia shedding of the deciduas
Alba and serosa are odorless
Menstruation shedding of the lining

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Breastfeeding
Form of birth control
Only up to 6 months
Suppress the activity of the ovary
Baby suckes stimulation of prolactin and oxytocin
Baby suckles stimulation of anterior pituitary (estrogen and
prolactin)
Only 1 or the other can be released
Estrogen stimulates ovulation so during breastfeeding prolactin I
released instead of estrogen
Prolactin increase production of milk
Oxytocin ejection of the milk
8 times of feeding
6 times daytime
2 times at night
at 6 months, introduction of other foods to baby decreased
breastfeeding estrogen instead of prolactin released
Is there a difference between menstrual and lochial discharge?
*Menstrual blood: NEVER CLOTS
Color: SAME
Smell: SAME
Amount: DIFFERENT (more on lochia)
Menstruation: 30-50 ml (max 80 ml)
Lochia: difficult to estimate
#of days of menstrual flow: 2-6 days
Lochia
Rubra: 3 days
Actual bleeding
Presence of clots: report
Serosa: at least 1 week
Alba: 3 weeks or more (3-5 weeks)
Braxton Hicks
Started at 4 months
Contractions more significant at 7th month
Decreasing level o progesterone at the last trimester increase
frequency of contraction
Labor
Decrease progesterone release of oxytocin
Prostaglandin theory
Hormone release by the when the body is stressed
Acts on the muscles
From the placenta, uterus, fetus
Sudden increase in prostaglandin
Mefenamic acid- prostaglandin inhibiting drug
Take on the day before you menstruate or at the onset of
menstruation
Uterine Stretch theory
When uterine is stretch to its max capability and capacity, it will
naturally contract and expel its contents
Natural protective capacity of the organ
*Conditions will stretch early
Twins (needs delivery; will deliver earlier) 2 weeks earlier
polyhydramnios
macrosomic baby
*Safe ang Sex even during pregnancy
Safe up to 34th week of pregnancy
Semen contains prostaglandin increase prostaglandin early
onset of labor
Fallopian Tube
As long as fallopian tube is healthy, fertilized egg can pass through
Isthmus
Ligated in tubal ligation
Estrogen propel by rhythmic movements
Progesterone nourishment of the zygote
Ampulla
Fertilization- outer 3rd of the ampulla (distal portion)
Fibrae
Cause of ectopic pregnancy
Surgery from tubal ligation (most common cause) (1% chance that it
will recanalized)
Pelvic inflammatory disease
Recurrent UTI infections
Development of the reproductibe organ- estrogen
Transport of baby through the tub (average of 1 week)
Never earlier than 7 (7-10)
Rhythmic contraction of the fallopian tube
Progesterone
Nourishment of the baby in the tube
Ovary/Ovulation
Primordial ova (at birth): 300,000-400,000
Immature follicle
Some die before they mature
By age 7: reduce to in number
Number that reach maturation: around 400 (200/day)
Menarche: 9-17 years old
Reproductive period: 35 years

Menopause
Perimenopause
2-10 years before menopause; hormone imbalance
34-60 years of age
Vasomotor instability, irregular periods, sleep trouble, irritability
Menopause
End of menstruation/Cessation of menses
Possibility that 1 or 2 egg cells are still in the ovary; risk of having a
baby with chromosomal defects
Post Menopause
1 year after menopause; very low level of estrogen
MALE
Scrotum - protects the testes from temperature
Penis - organ of copulation
Urethra
Releases urine and semen
Glans penis- with an angle so it could reach the posterior of the
vagina
Testes
Where sperm s produces
Epididymis
Store house of sperms
Vas Deferens
Conduit between the epididymis and ejaculatory dock
Seminal fluid with fructose
Prostate gland
Add volume of fluid
Makes sperm alkaline
Bulbourethral gland (Coupers)
Stimulated only during sexual arousal
Cleans the urethra
Ejaculate
2.5-5ml
at least 50,000,000/ml
Low sperm count: less than 20,000,000/ml
300,000,000 per ejaculate
Pre-ejaculation:
Irregardless of number, only 1 sperm can get a woman pregnant
If sperm is mature, can enter the womans uterus 80 seconds!!!!
Characteristic of the Sperm
Small head with long tail
Length of the tail is 10x the length of the head
Neck- gives energy to tail
Head- gives chromosomes
Tail- propels the sperm
Unidirectional- paakyat!
MENSTRUAL CYCLE
the start of every cycle is the menstrual cycle
Hormones
Hypothalamus: GnRh stimulates APG
Anterior Pituitary Gland: FSH, LH
FSH- stimulates development of graafian follicle
Leutenizing Hormone (LT) or Interstitial Cell Stimulating Hormone stimulates ovulation and development of ovary
The time the FSH stopped is the time of the sudden increase in LH
Ovary: Estrogen, Progesterone
Estradiol from the ovary
Estriol from the placenta
Progestin progesterone form ovary and placenta
Corpus luteum- 2 weeks
Albicans- dead corpus luteum
Corpus luteum degenerates corpus albicans decreased estrogen
and progesterone (ischemic) shedding of endometrium Bleeding
(Menstrual) start of the cycle
Low levels of E and P stimulate hypothalamus: GnRh stimulate
anterior pituitary gland release of FSH stimulates the follicle to
mature Graafian Follicle (increased ESTROGEN) Endometrium
Thickens (Proliferative)
Increased LH Ovulation Corpus luteum progesterone further
thickens at endometrium, more vascular ready for implantation
(Secretory)
FSH

LH
Estrogen

Progesterone

Menstrual phase- degeneration of the endometrium

Ischemic phase- corpus albicans
Menopause
Fsh is forever increased
Effect of combined birth control pills on ovary
Prevent ovulation
Menstruation
Degeneration of corpus luteum
Activity of ovary during Pregnancy

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No ovulation
Best hormonal requirement for ovulation
Increased FSH and LH
Suckling -> prolactin -> dec. estrogen
Average mentstrual blood loss = 30-50ml
Normal span = 21-28 days, at maximum 35 days
Oligomennorhea- prolonged intervals between menses
Polymenorrhea- short intervals between menses
Metrorrhagia intercyclic bleeding
Hypomenorrhea- scanty flow of bleeding, caused by nutrient
deficiency or hormonal imbalance
Hypermenorrhea/Menorrhea- excessive menstrual flow, caused by
endocrine imbalance, infection
Primary Amennorhea
Failure to begin to menstruate by 16 years of age
If absence of breast development or pubic hair, then consider
Turners syndrome (female with only one X chromosome)
No development of secondary sex characteristics
Menopause
Osteoporosis
Estrogen
Absorption of calcium
Retention of calcium decreased in menopause
Signs in Of Osteoporosis
Dowager hump (kyphosis)
Decrease in height
More prone to spontaneous fractures (wrist fracture common)
1.
Pelvic fracture- dangerous
Weight is on the area of the pelvis bone unable to support
Management
Walking devices
Allendronate (Fosamax) prevents bone resorption
2.
Take in the morning with plenty of water, 30 mins before eating
Stay upright for 30 mins after talking to avoid reflux and other GI
symptoms
Calcitonin allows calcium to go to the bones
Preventive Measures
Increase calcium in diet
1500-1800 mg/day
Exercise using the bigger bones/ weight bearing exercise
Walking
Stair climbing
Dancing

Avoid injurious activities

Sports with bouncing or jogging

Bone Density Scan once a year

Breast Cancer

1 out of 7,000,000

Prolonging the life the woman if diagnosed early

Breast Self Exam
Schedule: 1 week after menstruation when estrogen cant influence
breast tissue

Menopause: breast self exam at the same date every month

Breastfeeding: same date of each month
Steps
Face the mirror
Raise both hands
Should pull up at the same time
If one is pull down- unusual heaviness
Put your hand on your waist and lean forward
Must point at the same direction
Palpate (person should raise the hand at the back of the head
Circular
Tail method/Tail of Spencer (outer quadrant going to inner quadrant)
Feel for any lumps
Squeeze the nipple between thumb and forefinger to observe for any
discharge; abn if w/ secretion
Mammogram
Procedure to detect for any abnormal growth
Starts at age 40-50 years; d one every 2 years
51 and above: yearly
3.
Women of low risk category
Women of high risk category
From age 40, every year
With family history of breast cancer
Menopause after 50
Nulliparous
History of benign growth on the breast (fibroadenoma)
Heart Disease (atherosclerosis)
1 year after menopause start to increase cholesterol levels
Peaks at 5 years
Estrogen increases HDL decrease estrogen at menopause
decrease HDL increase LDL
Prevention:
Diet - reduce intake of fatty foods
Exercise

Stress Reduction
Lifestyle change
Exercise
Diet
Pap Smear
First papaniculao smear
Age:21
Earlier if sexually active (3 years after the first sexual activity)
Then annually until 3 consecutive negative Paps
I normal cells
II abnormal cells but not malignant, suggests infection
III abnormal cells, suggests malignancy, do cervical biopsy
IV abnormal cells, malignancy (no biopsy)
FAMILY PLANNING
After intercourse, diaphragm should be in place for 6 hours
3 year spacing of children; mandated by WHO
Major Program Policies of the Philippine Family Planning
Program
Improvement of family welfare with the main focus on womens
health, safe motherhood and child survival
Promotion of family solidarity and responsible parenthood
Nurses as EDUCATOR and FACILITATOR
How many methods: 6
Methods of Family Planning
Behavioral
Coitus Reservatus - no sexual activity
Coitus Withdrawal/Interruptus - with sexual activity
Sperm is not released inside the womans body
Not an accidental pregnancy unwanted
Never taught
Natural Family Planning
Principles:
The human ovum is susceptible to fertilization only for 18 to 24 hours
The sperms deposited in the vagina are capable of fertilizing the
ovum for no more than 72 hours
Present methods of determining ovulation are not exact by about 48
hours
Calendar Method
Ogino-knaus formula
Regular- same interval each time
Subtract 12 from the number of days of the menstrual cycle to
determine day ovulation
Abstinence starts 5 days before ovulation and lasts up to 3 days after
ovulation
Important: 1st day of the last menstrual cycle
9 days of abstinence Rule of 9s
Irregular- data of shortest cycle and data of longest cycle; for 6
months
Subtract 18 from the short cycle and subtract 11 from the long cycle
13 days abstinence
Answer of shortest to answer on longest abstinence
While waiting for 6 months, she can use other natural family planning
method
Menstrual interval
Interval between the first day of menstruation from the next
menstrual cycle
Basal Body Temperature
Any route for temp
Pre-ovulatory temperature is low because of high estrogen level
Post-ovulatory temperature rise is due to high progesterone level
How many will you abstain from day of change of temp: 3 days (egg
cell can survive for only 24 hours, 2 days leeway)
Symptothermal Method
Combination of mucus and temp method
More conclusive since it has 2 parameters
Billings/Cervical Mucus Method
Lactational Amennorhea Method
Chemical
Use of spermicides
Makes the vagina more acidic
Common side effect: vaginitis
Woman is not capable of protecting the vaginal wall
Delivery bases
Cream,jelly
Foam
Film
Suppositories mostly used in the PH
Foaming tablets
Common chemical agents
Nonoxynol-9 (N-9) kills sperm, virus, and bacteria
menfegol
benzalkonium chloride (BZK)

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Local barrier
Diaphragm

Dome shaped; mustbe fitted by MD

No protection from infection

Inserted up to 2 hours before intercourse and removed 6 hours after

intercourse to kills all sperms

Should be fitted exactly

Covers cervix and posterior portion of the vagina

Can be tilted during intercourse

Spermicide should cover inner portion, outer portion and rim of the
diaphragm
Cervical Cap
No protection from infection
Harder to place but one size fits all
The contraceptive sponge is moistened well with water and inserted
into the vagina with the concave portion positioned over the cervix;
may stick to the cervix
Wash hands thoroughly before inserting the cap
Wear it while upright placing one leg on a stool to feel the cervix
24-48 hours- time you can keep it
Longer than 48 hours develop infection toxic shock syndrome
Might develop cervicitis
Condom
Made of latex - allergenic
Female Condom
30% effective
Hormonal (Anovulatory menstruation)
Prevent pregnancy by inhibiting the hypothalamus and anterior
pituitary so that ovulation does not occur
Injectable
Depo-provera
Depo-medroxyprogesterone no estrogen, interfere with insulin use;
not given to diabetics
3 month injectable contraceptive containing 150 mg of synthetic
progestin
Increase (excessive) thickness of the endometrium
Avoid massaging the area immediate absorption effectivity less
than 3 months
Dont move site/arm increase absorption
Slow gentle wrist motion- prevent bubbles to give complete dose
prescribe
Cost effective; given ever 3 months; not readily reversible
Mixed slowly
Implant
Norplant
6.
Non-absorbable
Synthetic progestin
Implanted on the upper arm
Should be felt but not seen
Suppresses ovulation for 5 years
6 capsules of progestin are inserted SQ in the womans upper arm;
contraceptive effective lasts up to 5 years

2 years- 98-99%
a.
Every year minus 1%

Oral
Oral contraceptive pill; reversible
Available in 21 and 28 day preparation
7 placebo- iron supplement
Must be taken according to the arrow
1st day of menstruation- start intake of pill (28 day prep)
5th day of menstruation- start of intake of pills (21 day prep)
Take pill with food (after a meal)- prevent gastric irritation
Whatever time is convenient- best time to take the pill
If forgot to take the pill in the morning- take pill now then take pill the
time she regularly takes it the next day
If she forgot the day before- take double dose and continue regular
schedule
2 days missed dose, double dose today and tomorrow then return to
normal schedule
3 days missed stop taking and start and new one and use another
method
Side effect:
Nausea
Breast tenderness

Weight gain- 5 lbs. every year

Breakthrough bleeding
Adverse effect:
A- abdominal pain (severe), due to hepatotoxicity
C- chest pain (severe) or shortness of breath
H- headaches (severe)
E- eye problems (blurred vision, loss of vision), inc. BP
S- severe leg pain (calf or thigh) DVT
Mini pill
Progestin only
Morning after pill
Patients who are raped
Damage the development of the ovum
Contains a lot of estrogen

Contraindications
Undiagnosed vaginal bleeding
Thromboembolic disorders
Pregnancy terratogenic
Liver disease
Coronary artery or cerebrovascular disease
Heavy cigarette smoking effect on vessels
Breastfeeding suppress estrogen
INTRAUTERINE DEVICE (IUD)
A small, usually flexible appliance inserted into the uterine cavity
Inserted only when the woman is menstruating
To be also sure that woman is not pregnant
Only time cervix can open
Disrupts normal uterine environment; abnormal lining
MD insert instrument to measure length of uterine cavity insert
IUD as he pulls applicator
String is cut
Inhibits implantation through:
Local inflammatory response
Loal production of prostaglandins
Interfere with enzymatic and hormonal activity
Increase motility of ovum in fallopian tube
It immobilizes the sperms as they pass through the uterus
ABORTIFACIENT
Tell patient to check her string once a week for the first month
CHECK HER String once a week after insertion/once a month after
menstruation
Inserted during menstruation
If string not felt, go to doctor!
Progesterone-coated- changed every year
Copper T- every 10 years, spermicide
*Pelvic Inflammatory disease
Complication of IUD for 10 years
If woman with PID is still with IUD in place
Treat infection (antimicrobial) first before removal of IUD
Danger Signs
P- period late or skipped period
A- abdominal pain (severe)
I- increased temperature, chills
N- noticeable vaginal discharge; foul-smelling discharge
S- spotting, bleeding, heavy periods, clots
Surgical
Vasectomy
Local infiltration__> incision separate vas deferens pull out tie
cut
A minor surgery
Scrotal area will be swollen within 2-3 days
Can resume intercourse as soon as the inflammation subsides
Wear a condom (1 month)
2-3 times per week
Sperms are already produced
2-20- ejaculations needed to remove all ejaculation
After 1 month, get sperm count if negative wait for another month
get sperm count again
(-) (-)- OK na
3rd sperm count- 1 year after vasectomy
Sperms that are newly developed and cannot be released is
REABSORBED by the body
64 days production of new sperm cells
Ligation (BTL)
May equated to sterilization
Woman signs the consent but HUSBAND agrees to the procedure
Who should be present when MD discusses the procedure: BOTH the
couple
After delivery- Best time to perform because uterus is found in the
abdominal cavity
Easier to access the fallopian tube
Laparoscopic- introduction of air at risk for air embolism
A 3 cm abdominal incision is made through which the tubes are
tied/cauterized/cut
Interval mini-lap done during the first 7 days of the menstrual cycle
Post-partum mini-lap done within the first 8 weeks after a normal
delivery
*For DM patient
Unsafe ang pills affects insulin
Use barrier
Contraindicated to
DVT
Pregnant
Thromboembolic disorders
Liver disease
Coronary artery disease
Breastfeeding
Dont use pills that contain estrogen (depo-provera is OK)
Estrogen shuts down prolactin

Heavy cigarette smoking

PREGNANCY
Heartburn-pyrosis
Chloasma- face
Melasma- other parts
Cervical change- goodells
Presumptive
Subjective data
Patient complaints
Leucorrhea, pica, pyrosis, morning sickness, quickening, urinary
frequency, constipation
Probable
Objective
Positive pregnancy test, Goodells, ballotment, Chadwicks, Heggers,
inc. abdominal sign, Braxton hicks contraction
Positive
Diagnostic
Fetal heart (low pitch) - funic souffl (high pitch)
Fetal outline
Palpation of fetal parts by the examiner through Leopolds maneuver

Estrogen
Both
Progesterone
Vasodilating effect:
Varicosity Constipation
Hegars, Chadwicks
weakening of
Vasoconstriction effect
vessels and
Hormone that
Salt losing hormone
vasodilating effects Weakening of muscles
retains sodium; inc
Hemorrhoids
blood volume
Inc activity of ducts;
Inc. in T4: gamma
Edema- primarily
secretary function
globulin
estrogen but later
Decreased clotting
on progesterone
Genital changes;
factors
(too much salt was
growth of breasts,
Weakens the vessel
lost

stimulation
of
hypertrophy of the
walls
RAAS-- > increase
gums
Affects the mood;
sodium
Skin changesneuroendocrine effect
Breast changesstimulate
on behavior
primarily estrogen
melanocyte
oProgesterone stimulating hormone
changes in the
skin changes
breast
Decrease peripheral
vascular resistance
Neither
Waddling Gait-Relaxin- hormone from ovary
In mobility of the joints, abnormal gait of pregnancy
Morning sickness- Hcg

Gravida- pregnancy
Para - delivered - must be considered viable- greater than 20 weeks
Term - 38 -40 weeks
Preterm - 20-37 weeks
Abortion - below 20 weeks
Living - living as of now
Multiple pregnancies G,P,T counted as one, only in L is counted
Ectopic - counted in gravida and abortion
Stillbirth - Not counted in H
Hmole - Counted in gravida not in para
GP TAL (6 DIGIT DISTRIBUTION)
G TAL (5 DIGIT DISTRIBUTION)
Suspecting of pregnancy - considered as pregnancy
Segundi-2
Grand multi-5 and above

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Leopolds Maneuver
Systematic palpation of the pregnant womens abdomen to
determine several data
Explain what you will do to the pregnant women
To make sure that the results are accurate- tell the patient to void
Position: Dorsal recumbent
Draping Procedure: horizontal
Warm hands before palpation; Cold hands stimulate uterine
contraction
When to do Leopolds Maneuver: can be done at 5 months but best at
7-9 months
L1
Part of the fetus located at the fundus: cephalic or breech
Soft angulated, nonballotable buttocks
Hard, round, ballotable - head
L2
Flat plain (back), nodular/irregular several masses (fetal parts)
Fetal lie/ Fetal back
Longitudinal and transverse
Long axis of fetus and mother
Location of fetal heart
L3
Engagement
If floating, not engaged
If not floating and fixed, engaged
Presentation: Head, buttocks, shoulder

L4
Fetal habitus/Attitude occiput is the indication of position
A relationship of the babys parts to each other; degree of flexion
Flexion- normal attitude
Extension
Sincciput- head and hand presented
Position
Face the foot part place her fingers 2 inches above the inguinal are
glide downward find the occiput
Nonballotable mass- buttocks
Pregnancy
Fertilization
Union of a matured ovum and sperm
Each gamete has a haploid number of chromosomes
The sperm carries and X or Y sex chromosome
22 pairs- autosomes
Genotype genetic material
Phenotype physical trait
1 pair- sex chromosomes; determinant of sex
XXY Klinefelters Syntrome; male and female
XO Turners Syndrome no development of female sex
characeristics
Zygote- outcome of fertilization
Father determines sex of the child
Fertilization- sex of the baby is determined
2nd month or 8th week- formation of genitals
12th week- differentiated
(4th month) After 12th week- ultrasound to establish the babys sex
Y sperm - Move really fast but die fast
X sperm - Slow but sure
Zygote mitosis blastomeremorula (round, mulberry in shape,
found at the end of the fallopian tube) enters the uterus
blastocyst (ready to implant) inner and outer portion
Embryoblast
Inner
Fetal portion
Trophoblast
Outer will become placenta and fetal membranes
Amnion- fetal membrane
Chorion- placental portion
Decidua
Basalis
Basalis
Placental portion
Vera
encapsularis
Placenta
Protective barrier
Cytotrophoblast and syncitiotrophoblast
Present
Prevents crossing of treponemapallidum
2nd trimester- syncitiotrophoblast remains only
Organ of the baby in utero
Endocrine/Metabolic activities provides hormones of pregnancy
E,P,Hcg, hPL (fetal growth hormone)
Transport function nutrients,m stores iron for 6 months
Endocrine function
Immunologic IgG from mother at 34 weeks (9 months, passive
natural immunity, all diseases)
Milk have IgA; protection from diarrheal diseases
Protective barrier against harmful substances (drugs and
microorganisms) However, viruses may enter
Give only tetanus toxoid
Oxygenation
Excretory organ
Wastes by baby excreted by maternal liver and kidney
Umbilical arteries waste products
Umbilical vein oxygenated blood
Result of the union of the chorion and the decidua basalis
Chorion - source of the primary villi
Chorion chorionic villi release enzymes attach to maternal
vessel and get blood blood goes to space called lacunae (blood
lake) several lacunae will form cotyledon more cotyledon will
form placenta (15-20 cotyledons)
1 week after fertilization (after implantation)- Start of placental
formation
3rd week- circulation starts
3rd lunar month- complete its formation
Grows until 20 weeks covering about of the internal surface of the
uterus
Corpus luteum
Kept alive by hCG
Maintain the endometrium to nourish the baby
HCG will rise up to the 3rd month
Prevents involution of the corpus luteum

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Basis for pregnancy tests

Present in maternal blood 8-10 days after fertilization (as soon as
implantation occurs)
Level doubles every 2 days
Nauseated morning sickness
3rd month, placenta takes over E and P decrease hCG
degeneration of corpus luteum; morning sickness subsides
Hyperemesis Gravidarum
Excessive vomiting beyond 1st trimester
Can be seen in H-mole
Ectopic Pregnancy
Level of hCG will not increase above 3 months
Management:
Methotrexate- stop development of cells
Completed if hCG levels will decrease
Abortion
Normal hCG then it dropped assessed through serum hCG
H-mole
Fertilization of an empty ovum
Only placental portion is forming (chorion)
No amnion
Human Chorionic Gonadotropin
Establish pregnancy through urine
7th or 8th week- presence of gestational without a baby
Ultrasound at 1st trimester
Pregnancy testing
She missed her period today, when can she take the test: TODAY
Done in the morning
First void
Midstream collection
Done again a week later if negative at first
IgG- 2 weeks before delivery passed to baby
Heparin- safe for pregnancy
Cannot cross placenta
Coumadin- can cross placenta
Anything that happens to the placenta facts the baby
You save the placenta until the MD orders it to be disposed
Placental Aging Theory

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When the placenta degenerates stimulation of labor

Ultrasound- determines the placental age
By the amount of calcification or amount of are that is calcified
Grade 3- fully matured placenta (38-40 weeks)
Placenta premature degeneration

Blood going to the placenta is decreased placenta degenerates

42 weeks- maximum weeks the baby can stay at the placenta
Umbilical Cord
length of the cord estimates the length of the baby
Short- might develop abruption placenta
Long- at risk for cord coiling
Haases rule
1-5 months = Month2
6-10 months = Month x 5
A-V-A
Vein carries the 02 blood (placenta to baby)
Arteries (baby to placenta)
Whartons Jelly
Fluid filled connective tissue to connect the baby to the placenta
It has fluid to prevent compression of arteries and vein in the
umbilical cord
Cord Prolapse
Concealed inside the vagina; elevate the hip
Apparent outside the vagina
Gold Standard Answer: CHECK THE FETAL HEART
Ask mother to lie down check babys heart rate
Insert a gloved finger into the mothers vagina to check for cord
prolapse
Position mother to knee chest
Trendelenburg is not advisable compression of diaphragm
Left side lying- put pillows on the hip to elevate it
Apparent
Never reposition the cord compressed more
Make sure cord will not shrink
Cover with sterile gauze with warm NSS to vasodilate and prevent
atrophy
Continuous irrigation
CS- only means of delivery
Emergency Situation
A clean cloth is OK

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Amniotic Sac and Amniotic Fluid

Functions
Cushions fetus against mechanical injury
Maintains a steady temperature in utero (most important)

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Allows freedom of movement -> change in position of fetus ->

musculoskeletal development
16-18- multipara
18-20- primipara
Prevents drying of skin
Permits symmetrical growth of the baby
Prevents adherence to the amnion of the fetus
Source of oral fluid for fetus; of 1000ml, 400 will remain, 600
recycled
Excretion collection system
Kidneys start making urine around the 2nd month
Continuously produced by amnion and fetal urine
4th month- increased production because of fully matured kidneys
800-1000 ml- normal volume of amniotic fluid
7-7.25 - pH
Oligohydramnios
Less than 400 ml
Decreased urine production
1 kidney (anomaly); Very small kidneys
Suggestive of Downs syndrome
Polyhydramnios
Greater than 2000 ml
Decreased capability to swallow (Tracheoesophageal atresia)
Diabetic frequently
Multiple pregnancy
Color
Slightly yellow in color, cloudy
Not deep yellow- bilirubin mixed in the fluid
Erythroblastosis fetalis
Xanthochromic RH incompatibility; yellow fluid
Green tinged- meconium stained
Needs suctioning to prevent aspiration pneumonia
Because of fetal distress (cephalic)
CS- management
Fluid is also swallowed by the baby
Suctioning
Because of breech presentation (normal)
Abdomen descends increase pressure defecation of meconium
Red wine - mixed with blood
Abruptio placenta
CS- management
Nitrazine Test
Lithmus paper test
Blue- positive rupture of membrane
Premature Rupture of Membrane
No option to continue the pregnancy might lead to chorioamnionitis
Fatal
Infection of mother and baby
Leaking fluid from the vagina
Management
IV antibiotics
CS
Early Rupture
Membrane ruptured before transitional phase
Latent period- 3cm dilation
Active- 4-7 cm
Transitional- 8-10m
Cod Prolapse
Prolonged Labor
Pressure exerted from the placenta helps the cervix dilate
Will cleanse the vaginal wall
Dry Labor
Amniotic fluid makes the vagina more slippery
Management: use KY jelly
Ballottement
Insert gloved fingers into the vagina tap the cervix bouncing
movement of baby
FETAL DEVELOPMENT
Zygote first 2 weeks
Embryo 3 to 8th week
Period of organogenesis
Fetus after the 8th week until delivery
Period of rapid growth
Social drugs cross addition; withdrawal symptom; get 1 st urine
sampling
Smoking SGA due to vasoconstriction
Thallidomide (antiemetic) phocomelia
Lithium, Streptomycin,Kanamycin damage to 8th cranial nerve:
deafness
Tetracycline staining of permanent teeth of baby
Valium can lead to cleft palate defect
Intrauterine development
Pre-embryonic
Ovum zygote embro

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0-2nd week
Embryonic
3-8th week
Important period
Organogenesis
Fetal
8th week onward
2 weeks- heart (beats on the 25th day)
3 weeks- brain/CNS development (B9/folic Acid, glucose)
2 months
Separation of GI and respiratory tract
Sex organ develops
Meconium in the intestine
Respiratory structure are not yet formed
Rubella- most dangerous
Can damage structures of the baby developing at that time
Underdeveloped structures (microcephaly, glaucoma, cataract,
defect in 8th cranial nerve, mental retardation)

1-3 months- 60% chance of damage

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4 month- 10% chance
5th month- no chance of harming the baby
Vaccine NOT safe to be given give GAMMAGLOBULIN
After deliverycan have vaccine
Cannot get pregnant for 3 months
Chicken Pox
Women in the first 7 months of pregnancy have a very high immunity
for chicken pox
After the 7th month (last trimester) at risk for chicken pox
If with chicken pox during delivery, after delivering the baby separate
first mother and baby to prevent transmission
Can have chicken pox vaccine after delivery but cant get pregnant
for 1 month
3rd month (fetal period)
Growth in size and weight
Sex is well differentiated
Ossification- bone formation and development
Increase intake of calcium
800 mg (2 servings) 2 glasses of milk + 400 mg for the baby
If decreased calcium intake baby will get calcium from mothers
bones decreased bone integrity of the mother looses her teeth
Sources of calcium
Dairy
Green leafy vegetables
Fish bone (sardines)
Egg yolk (2 eggs per week)
End of the 3rd month: ideal time from UTZ
4th month
Amniotic fluid is recycled as urine
Quickening
Vernix/Lanugo
Can do amniocentesis
5th month
Fetal heart rate
Can be heard as early as 3 months (Doppler)
4th month (fetoscope)
4-5th month (steth)
120-160 bpm
Quickening (Primi: 18-20 weeks; multi: 16-18 weeks)
ballotement
6 month
Regular sleep wake cycle
Neurological functioning has began
20 hours a day
Awake- at night (hungry); at morning when mother eats (30 minutes;
increase supply of glucose to baby)
Fetal movement count
First movement is the start of the time
10-12 movements/hour (Cardiff Protocol)
Must eat first before counting
Empower mother to know the condition of the baby
Less than 4 movements in 24 hours- danger sign; do biophysical
scoring
Non Stress Test
Ultrasound
Vernix caseosa for temp regulation
7th month
alveoli opens (surfactants are present) start of lung maturity
No surfactant
Fat deposits under the skin
Weight is doubled
Red and plethoric
8th month
AOG
26-27
wks

L/S Ratio
Secretion into alveolar space
begins

Lung
Maturity
Viability
attained

30-32
wks
35 wks

1:2:1
2:1

Maturity
attained

Phosphatidyl glycerol
Phospholipid only noted when the fetal lungs are mature (most
important indicator)
Amniocentesis
Test to establish lung maturity
Not a routine procedure
Gives information on fetal:
Genetic testing (early part of pregnancy)
Hemolytic Diseases (middle)
Pulmonary Maturity (late) L:S ratio
Sex
Alpha-feto protein (early)
Enzyme only elevated when there is a break in the neural tube
Spina bifida
Elevated- Spina bifida
Very low- Down syndrome
Can get from maternal serum (maternal serum alpha-feto protein)
Not conclusive
Only a screening test
98% percent tested positive result but only 1% is with defect
Hemolytic Disease
Color of amniotic fluid
Pulmonary Maturity (organ maturity)
Check babys lung maturity and kidney function
High level of creatinine- kidneys are functioning
High level of bilirubin- liver problems
Done first with ultrasound: FULL BLADDER
Amniocentesis: EMPTY BLADDER
MOST IMPORTANT: Check signed consent
What will the nurse prepare before amniocentesis: ultrasound
Abdominal- full bladder (more common) 1 -2 glasses of water
Vaginal ultrasound- empty bladder
After obtaining ultrasound empty bladder to facilitate
amniocentesis
Sterilize area use sterile needle
Use local infiltration
Aspirate; should not be exposed to direct light
Area of puncture should have adhesive
Normal side effect
Slight leaking of fluid in the area of puncture
Baby moves more frequently than normal
Slightly increase in fetal heart rate
BP of mother slightly increased
For 2 hours only
Greater than 2 hours- admit to hospital
Abnormal Side effect:
Leaking fluid from the vagina premature rupture of membrane;
early labor check for pH
Abortion 1;200 (early)
Early labor (late)
Determining EDC
If known LMP, use Nagels Rule = -3 +7 +1
If not known, use Bartholomews Rule abdomen is divided into
quadrants
McDonalds Rule get the fundic height (cm) x 8/7 = AOG in weeks
Kung ano yung sa situation, yun yung AOG.
DO not get the lower number
Johnsons Rule Fh (cm) n x 155 = g.
N = 11 if the part is not engaged
N = 12 if the part is engaged
Maternal Changes during Pregnancy
Head
Hair- grows faster and longer
Stimulated by estrogen
Old hair that is growing fast
6 months postpartum- lose old hair
Dont use hair treatments goes to the baby
Chloasma
Bony prominences exposed to the sun
Mask of pregnancy
Freckles
Dark people - darker areas are on the creases
Only temporary
Melasma
Other parts darkens
Not noticeable in multipara
Nose
Nasal congestion
Increased vascularity
At risk for epistaxis, advise to open mouth

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Gums
Hypertrophied
Use soft-bristled toothbrush
Advise to check-up with dentist
At risk for losing teeth can never have tooth extraction because of
anesthesia
Pagnatanggalanng teeth strep might go inside gums teratogenic
Increased salivation
Chew fruits
More acidic
Tooth erosion
Frequent use of mouth
Decrease bacteria in the mouth
Pica
Craving for nonfood or nonnourishing food
Decreased nutrition for the baby
Provide protein to the diet
Treatment for anemia
Nonfood
Clay
Charcoal
Toothpaste
Chemical mother ingest can be dangerous for the baby
Refer to psych
Breast
Enlarges
Estrogen stimulates ductile structures
Progesterone stimulates secretory gland of the breast
Pre-colostrum
Present at 4th month (16th week)
Not the real milk but a precursor of milk
Yellow
How many days will it take to empty the breast of colostrum: at least
3 days
Up to 5 days for primipara
Immediately after delivery put the baby on the breast (without

airway obstruction)

CS- slightly delayed breastfeeding (4 hours after pa pwede)

Wear bra support

Strap supports
Nursing Bra
Thick strap
With opening for easier breastfeeding

Abdomen
Darkening of the LiniaNigra
Abdominal Striae (stretch marks)
Gravidarum- dark brown
Albicantes- whitish
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Postpartum
Diastasis Recti Abdominis
Overstretching of the rectus abdominis muscle
Abdominal exercise up to 5 months
Beyond 4 months- left side lying position
Bartholomews rule of 4
Determine age gestation fundic height
5 months- umbilicus
Lightening- lowering of the uterus
Engagement- lowering of the head of the baby
McDonalds rule
Using tape measure to get fundic height in cm x 8 / 7
Yung given na cm, malapit dun yungaog
Usually higher

LMP
Jan-march
G
April-Dec
-3 +7 +1
Vagina
Mucus plug- operculum

Less acidic- more prone to infection

Legs
Edema
Poor venous return (too much pressure on the lower part of the body)
Low salt diet
Management:
Elevate- up to 3 pillows
Edema on nondependent areas is abnormal
Lower lid and fingers (+3)
Weight gain
1-3 months- 1 lb. per month
4th month and above- 1 lb per week
Filipino: up to 12 kgs or 25 lbs

Varicosity
Due to weakening of the blood vessels and vasodilation
Pressure of the uterus
Avoid prolonged sitting or standing

Elevate with pillows (up to 2)

Vulvar varicosity
Put pillow on hips to elevate
To decease risk of rupture put sanitary pad (at least 1 layer)
Sexual Activity
Safe during pregnancy
Dont do nipple stimulation during foreplay stimulation of oxytocin
No oral-genital stimulation (not to blow air inside the vagina)
pressure is introduced can rupture and open up the vessel air
embolism
No douching air embolism
Cramps
Calcium-phosphorus imbalance
Lightening and engagement pressure on the sciatic nerve
cramps
No prevention
Just stretch and dorsiflex the foot
No massage (might dislodge thrombus)
Stretch and dorsiflex the foot (safest)
Place warm compress only if there is no varicosity
Scenario: foot is on the stirrups cramps take the leg off the
stirrups then dorsiflex
Scenario: crowning of the baby keep leg on the stirrups dorsiflex
the foot
Stockings: best to prevent venous dilation (but is not always the
answer, depends on the situation)
Sit every 2 hours
Nutrition
Pregnant: 1700, Additional 300 calories
Breastfeeding: additional 500 cal, addtl protein
SYSTEMIC EFFECTS OF PREGNANCY
Cardiovascular
Sudden increase in blood volume
45-50% (plasma only)
With iron treatment - Can increase cellular component by 30%
No iron treatment - 10% lang
Iron treatment - 2nd trimester to prevent deficiency in 3 rd trimester
Prone to infection
Easy fatigability, shortness of breath, palpitation
Exercise:
Whatever she did before is safe except contact sports
Floor exercise = side lying on the left
Pelvic rocking and tailor sitting for backache
NO CONTACT SPORTS
Increased hematocrit - physiologic or pseudoanemia
Cardiac rate- increased by 10 beats per minute
Increased WBC
Slight elevation
Not a significant sign
Significant if accompanied by other symptoms of infection
Increased coagulation
BP decrease during the second trimester, return to normal during the
3rd
Advised pregnant woman to wear seat belt, no driving pag 7 months
na
Traveling by plabe is not safe in the last trimester
Boat rides not safe during 1st trimester
Uterus
As uterus grows in size goes into the abdomen woman lying on
back uterus pushed to the right side pressure on vena cava
uteroplacental insufficiency fetal heart (distressed)
Non-pregnant uterus- needs 15 ml/min of blood
Pregnant uterus- 500ml/min
Upright- uterus will find a space in the abdomen
Side sitting and side lying safe
Raising right part paramatiltyug left prevent hypotension
Angiotensin gene T235- will not allow you to respond to estrogen
normally (afro-americans)
PIH
At risk for PIH:
Old
Smoker
With T235 gene
Test:
Roll over position
One on flat and one od side lying
Get BP
>20 diastolic (+) hypertension
Respiratory System
Inc CO2 level > effect of progesterone and fetal waste effect
depends on patient


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TEATMENT OF CHOICE IN ASTHMATIC PREGNANT: B-adrenergic

agonist Bricanyl same drug used in premature labor, tocolytic
Risk for arrhythmia use beta blocker; Propanolol
Any steroid is not safe during pregnancy!
Prone to hyperventilation = deep breathing
Blow through a brown bag or cupped hand
Nasal congestion
Difficulty of breathing
Renal System
Pressure on the bladder (first and third tri) >
Inc renal perfusion > Increased glomerular filtration rate > inc output
(low specific gravity)
Glucose threshold drops (due to progesterone)and more glucose
likely to be expelled thru kidneys thus will see an increase in insulin
demand after 24th week
To check for GDM use serum glucose because urine will always
have glucose during pregnancy
Enlarging of the uterus add pressure to the bladder
Frequency
Beginning of pregnancy because of pressure to the bladder
Later during the lightening because of the descend of the uterus
Urgency
If there is discomfort possible UTI irritable bladder syndrome
premature labor
Aldosterone production increases
Increase in sodium and fluid retention
If with kidney failure
Both can be used as long it is consistently monitored because both
are at risk
Urine sample is good within 2 hours
Heat and Acetic acid test
Get urine 2/3 full heat
If clear- ok
If cloudy put acetic acid
If clear- increased lang ang protein intake the day before
If cloudy albumin determination (24 hour urine collection)
Musculoskeletal
Changes ion center of gravity as pregnancy progresses
Lordosis - back pain
Prevent back pain
Maintain postural alignment of the spine
Sit on the floor (tailor sitting position) (Indian sitting)
If with back pain: Pelvic rocking position
Cramping in calf from hypocalcemia or hypercalcemia
Progressive softening of the cartilage
Waddling Gait (inc mobility of pelvic joints) due to RELAXIN form
ovary
Shoes
Any shoes that are low heeled
Wedge
Rubberized
Can they use bath tub: yes
Somebody should assist her in getting in and out of the tub
Should be rubberized
1st trimester no boat ride because of nausea/vomiting
3rd trimester no airplane since change in pressure may sti
contraction
Safest: Automobile, must ambulate every 2 hours for circulation for
15 mins
Neurological
Pressure on the sciatic nerve in third trimester
Cramps
Gastrointestinal
Bleeding gums
N/V
First trimester due to increased hcg
Cravings/increased appetite
Smooth muscle relaxation (Progesterone) > decreased
peristalsis
Heartburn or Pyrosis
Eat slowly (chew 10 times before swallowing)
Eat small frequent feedings (especially in the last trimester)
Avoid fats and spices
Fiber should be cooked
Can be given antacids
Aluminum magnesium combination
Prevent GI complaints
Maalox - only antacid that is lowest sodium
Abdominal cramps
Decreased peristalsis due to progesterone
Gas constipation
Heartburn

Constipation and gas

Never laxatives since it will stimulate the uterus to contract
No oil based preparation since it hinders fat soluble vitamin
absorption
Stool softeners are ok (Colace)
Morning Sickness
Phenomena only in the morning
hCG
Because of Hypoglycemia (baby used up all her glucose
Eat crackers before getting out of bed
N/V (hyperemesis)
Pernicious vomiting
Vomiting that ffects food intake
All throughout the day
Met.Alkalosis
Persistent vomiting
Exceeds first trimester
Starvation vomiting
Met.acidosis
Causes
H-mole remove the mole
Psychological cause - Level of maturity should be assessed
AGE IS IMPORTANT FACTOR
Cracker-water combination
Give cracker, wait for an hour, if ok, give sips of water, the if ok
repeat every hour
2 days NPO 3rd day water-cracker soft diet full diet
Endocrine
Anterior pituitary gland:
decreased FSH
ncreased LSH
Increased oxytocin secretion during labor and delivery
Ovaries secrete relaxin
Increased flexibility of joints
Increased thyroid hormone
Increased BMR
Increased demand for insulin from pancreas
Production of relaxin
Hormone that permits relaxation of hip joints in preparation for child
birth
Psychosocial Task
Maturational Crisis
Situational Crisis
First Trimester
Period of ambivalence
TASK: Acceptance of pregnancy (assess maternal feelings, support)
Second Trimester
Acceptance and fantasy
Fantasy about the baby
Might have an ideal child in her head might have a different child
TASK: Fetal Embodiment (accepting the baby as separate from self
Last Trimester
Fear of delivery
TASK: Preparing for child birth or fetal separation
Introduce childbirth classes
Lamaze psychoprophylaxis (conditioned response)
Bradley natural childbirth; husband coached; no medication;
oxytocin released through nipple stimulation
Dick Read - hypnosis
Fatherhood
Mittleiden- to hatch observes behaviors and taboos associated
with pregnancy
Couvade- means suffering along
Psychosomatic symptoms felt by the husband while the woman is
free from the same
Toddler
Relay news of pregnancy when there are signs of pregnancy
School Age and Adolescent
Relay the news as soon as pregnancy is confirmed
High Risk Factors
Age = 18 and below; 35 and above
Height = 410
Weight less or more than 20% of ideal body weight
Parity = Primi; G5 above
Nutrition deficiency: CHON deficiency
Low socioeconomic level
History
Medical = DM, HPN, Heart disease
Gyne: STI, infertility
Surgery: abdominal
OB: Bleeding, PIH
BLEEDING COMPLICATIONS
First

Second

Third

Trimester
Ectopic
Abortion

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Trimester
H mole

Trimester
Placenta
previa
Abruptio
placenta

Abortion

Loss of pregnancy before fetus is viable (<20 weeks)

Early Abortion- before 16 weeks AOG

Late abortion- after 16 weeks AOG

More dangerous
Possible DIC
Spontaneous Abortion
Also known as miscarriage; 15-30% of abortion
1.
2.
Chromosomal abnormality
3.
Infection that damages organs of the baby
4.
Endocrine disturbance (Hyperthyroid)
5.
Trauma
6.
Incompetent cervix dilates w/o uterine contraction
Induced Abortion/Therapeutic
Performed to save the mother
Ectopic pregnancy
Habitual Abortion - 3 consecutive times or more abortions
Incomplete Abortion
Fetus is expelled
Placenta retained
Management- D&C, suction curretage
Complete Abortion
All products of conception expelled
Mgt: methergine, antibiotic (pennicillins), pain meds (mefenamic)
Threatened Abortion
Painless spotting with not effect on fetus
2 weeks rest: Complete bed rest; soft diet given sedatives to prevent
stimulus for contractions; sex resume after 2 weeks
Missed Abortion
Fetus dies in utero and is retained
No caesarean section
Drugs to contract the uterus
Laminaria dried seaweed that is sterilized, absorb the fluids,
expand and painlessly expand, then given misoprostol (Cytotec)
intravaginally and Oxytocin (Pitocin) per IV
D&C to remove the placenta
Signs and Symptoms:
Threatened Abortion- cervix is still closed
Vaginal bleeding/spotting
Painless
Inevitable/ Imminent
Fetus and clot expelled
Vaginal bleeding may be heavy, pain on abdominal area and radiates
to the back
Contractions
Cervix dilated
Management
Complete bed rest
Soft diet: Prevent constipation prevent straining
Sedatives - stress can predispose the abortion of baby
Admission in hospital only for observation to observe for further
bleeding
Cerclage
McDonalds- temporary (12-14 weeks) (NSD)
Shirodkar-bar- permanent
Purse String
Delivery by CS
D&C
Safe all the tissue that passes out for histopathology
Might scar endometrium possible placenta previa on the next
pregnancy
Help cervix dilate (induction of Labor)
Laminaria- seaweed introduced into the cervix; will swell if absorbed
water cervical dilation
Misoprostol (Cytotec)- prostaglandin that increases blood supply to
the cervix (more dilatable) softening of the cervix
Oxytocin (Pitocin/Syntocinon) - contraction of uterus
Dead baby can be expelled
Placenta removed through D&C
Possible DIC to mother
Home Management
Restriction at home for 2 weeks
Can have sex after 2 weeks
Can go back to work after 2 weeks
50% of threatened abortions lose their babies
Causes
Genetic defect in the baby
Endocrine factors
Hyperthyroidism
DM (rare)

Infection
Systemic disorders
Psychological factors
Medications can be terratogenic
Incompetent cervix
Can be managed surgically
Dilates without uterine contraction
Frequent dilation- D and C
Habitual Abortion
Complication: Missed Abortion - DIC
Classical CS incision - forever CS
Medical Therapeutic for Spontaneous Abortion
Ultrasound
Bed rest
Intravenous fluids
Possible blood transfustions
D&C
RhoGAM given within 72 hours post delivery, post amniocentesis and
after D&C
ECTOPIC PREGNANCY
Pregnancy outside the uterus
Sites
Fallopian
If in isthmus - more bloody (closer to uterus); can be expelled
vaginally
70% tubal
If in ampulla- chronic bleeding (more dangerous)
Acute on the isthmus; bleeding form rupture may go to the uterus
and manifest outside
Chronic on the ampulla; bleeding form rupture goes back and goes
to the cul-de-sac (Cullens Sign)
May compress phrenic nerve; shoulder pain upon respiration; same
side with ruptured
May go to shock
Manifestations
Cullens Sign
Bluish discoloration in the umbilicus hematoma because of the
bleeding underneath the peritoneum
Cul-de-sac mass
Normally it is hollow
Shoulder pain
Referred pain
Compression of the phrenic nerve
Side of implantation
Unilateral, lower quadrant, on and of colicky pain (not ruptured),
sharp one-sided pain (rupture)
Ovarian Ectopic
Rhythmic contractions of the fallopian tube pushes the zygote
backward to the ovary
Cervical Ectopic
Hypermotility of the zygote then implants itself in the cervix - IUD
Cervix has low blood supply cannot fully nourish the baby
Remove the portion of with the fetus then cerclage is done
Abdominal
Laparotomy done to get the baby
Placenta is retained in the attached organ
Will naturally degenerated
Medical Treatment for Ectopic Pregnancy
Administration of methotrexate IM (prevent multiplication)
Surgical treatment salphingostomy via laparoscope
Risk Factors:
History of PID
IUD
Abnormal tube
Endometriosis
Abnormal thickening of the endometrium due to hormonal imbalance
Estrogen
Management- androgen (male hormones)
Can damage the liver
Given Depo-provera
40% of young women are at risk
HYATIDIFORM MOLE/MOLAR PREGNANCY
Gestational trophoblastic disease - proliferation of the trophoblasts
(bigger than age of gestation); no embryoblast
Trophoblast > formation of amniotic fluid > elevated HCG
Benign - precursor of choriocarcinoma (malignancy)
Inc. FH, No FHT, hyperemesis, red or brownish vaginal bleeding which
may also include vesicles (diagnostic!)
Degeneration of the chorion into the fluid-filled grape like chorionic
epithelioma
NO CAUSE
Risk Factors

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Extremes of age - very young and very old

Genetic - Asian women
Low protein diet
Use of Clomid stimulate excretion of egg cell that is empty (fertility
drug)
Manifestations
Increase in fundic height
Increased hCG
Hyperemesis
No fetal heart tones
Red, brown vaginal discharge
Ultrasound reveals mass without fetal skeleton
Snowstorm pattern
Management
Suction evacuation of the mole
hCG monitored after
Curettage - if she still wants to become pregnant
Labs drawn serial hCG monitoring (blood)
CXR to establish if metastasis is seen
Birth control for minimum of one year
If mole is cancerous chemotherapy (methotrexate)
Hysterectomy
Monitor level of hCG for 1 year after surgery
Teach the patient to delay pregnancy for 1 year
Follow up for choriocarcinoma
Provide emotional support
Methotrexate- drug of choice for choriocarcinoma
Since it is folic acid antagonist, free from folic acid diet since it will
neutralize the effect
Chest x-ray
To determine if there was metastasis to another area
Lungs- most lymphatic organ
Use birth control (Combined birth control)
PLACENTA PREVIA
Low lying placenta/ attachment in the lower uterine segment
Risk Factors
Uterine abnormalities
No invasive History of uterine surgery
Causes:
Unfavorable deciduas
Multiparity
Twins (dizygotic/fraternal) different placenta
kung sino unang kumapit, sya yung nauna
Manifestations: Painless, bright red bleeding from the placenta, soft
uterus
Dx : Ultrasound
Types
Low lying - placenta is very near the cervix but does not cover it
May be NSD, may have minimal bleeding, double set up when
bleeding occurs
Marginal - 1 cm before you touch the placenta
Partial placenta covers 50% of the cervical ox
Complete/Total - placenta covers the entire cervical O
Excessive bright red bleeding with no pain, not in bleeding
Directly CS
Management
No IE in suspected previa
treatments
Only through CS (partial and total)
NSD (marginal and low lying)
Double set-up: NSD and CS
Complication
Bleeding because area of attachment (lower part of uterus) does not
contract
ABRUPTIO PLACENTA
Sudden complete/partial separation of a normally implanted placenta
after 20th weeks AOG
OBSTETRIC EMERGENCY
Risk Factors
HPN
History of placental abruption
Multipara
Substance Abuse
Types
Partially or Completely Separate
Concealed
Separation at the middle
More dangerous
Blood will not b able to come out sink into muscles board-like
rigidity (internal bleeding)
Shultz, Couveaire
Apparent separation from marginal area where blood mixes with
amniotic fluid
Assessment

Sharp like abdominal pain

Board-like abdominal pain (Couvelaire)
Changes in the shape of the uterus
Usually w/ vaginal bleeding - Dark red (not fresh blood)
Middle of pad- scant
Fully saturated pad- 30 ml of blood
1/3 pad- 10 ml
S/Sx of shock fetal distress (bradycardia)
Assess abnormal coagulation
99% of babies die
Environment is the priority, Nursing Interventions must primary be
directed to the patient
Management
Position on modified trendelenburg
Blood from the extremity will go to more important organs
Keep patient warm
Cover her with several layers of sheets
Monitor CVP
Right pressure of the heart
If increased- slow down the IVF to KVO
Fluid volume deficit
Priority nursing intervention
Then altered perfusion
Previa
Low implantation
Bright red
Painless
Soft uterus

Abruptio
Sudden separation
With or without bleeding
Painful
Couvelaire uterus

Emergency Implementation for Bleeding in Pregnancy

Alert the health team to provide maximum coordination of care
Place woman on modified trendelenberg or left side lying (minimal
bleeding)
Begin IV with a gauge 18-19 needle in anticipation of blood infusion
NPO in anticipation of surgery
Administer oxygen PRN at 2-4 L/min to provide adequate fetal
oxygenation despite decreasing circulating volume of blood
Assess blood loss (weigh pads), FHR, VS, I and O, Uterine
contractions
Omit vaginal or rectal exam
Order type and cross match 2 U whole blood to restore maternal
circulating blood
Assist with placement of CVP (assess pressure of blood that goes to
the heart)
Pulmonary wedge pressure (pressure that leaves the heart)
Rise in CVP put to KVO
Low in CVP hasten delivery
Set aside 5 ml of blood in a test tube and observe if it will clot in 5
mins. If it did not clot, suspect DIC
Maintain a positive attitude towards fetal outcome to maintain
bonding

PREGNANCY INDUCED HYPERTENSION/ TOXEMIA

PIH
Seen on 20-24 weeks
Accompanying symptoms are
hypertension, edema, and
proteinuria
Ecclampsia - convulsions
BP will be normal after 6
weeks

Chronic HPN
Seen before 20 weeks
No proteinuria
No convulstions
BP will remain elevated after
6 weeks

Noted in the second trimester

Risk
Primipara
Young and old
(+) HPN in hypertension
Low socioeconomic group
Low protein diet
Manifestation
Edema
Proteinuria
HTN
Has convulsion
Corrected within 6 weeks after delivery
Cause is unknown; due to hormonal change
Stages
Stage 1 (Pre-ecclampisia)

Mild (Home
Management)
BP 140/90
Edema of finger and face
Proteinuria +1 (<2g/day)
less than 2 g of protein per
liter

Severe (Hospitalized)
BP 160/110 or above
Anasarca third spacing
edema
Proteinuria + 3 or 4 (more
than 2g/day)
Epigastric pain (aura)
Visual disturbances inc ICP
Altered sensory and
perceptual function

o
o
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Management
Mild
Bed rest on left side
Diet alterations: High protein, low fat, low salt
Normal CHO to avoid use of protein for energy
Monitor fetal status times two of normal visit
Twice a week on the last month
Severe
Altered perfusion
Altered sensory and perceptual function (priority) promote quiet,
non-stimulating environment
Room of patient is 20 feet away from the nurses station
Limit visitors to visiting time to promote rest and sleep
No TV and close eye work
High protein, low salt, low fat
Bed rest anticonvulsant medications
Fluid and electrolyte replacement
Corticosteroids are given: bethamethasone
Anti HTN meds
Magnesium Sulfate (TL: 4-8 mg/dl)
Anticonvulsant
IM bolus, Buttocks, Deep IM, Z-track
Check DTR,RR, BP, FHR, I&O(released through the kidneys; monitor
I&O; maintain 30 ml before giving next dose) before giving first dose
Prepare calcium gluconate; max of 8 hours
May be replaced by Hydralazine (vasodilator)
Potassium sparing (non-thiazine) because loss of potassium can
affect the heart
12 gms- respiratory distress
>12 gms- circulatory collapse
If IV- use soluset - over a period of 20 minutes
Stinging to the tissue - lidocaine is added to decrease pain
Magnesium sulfate first before lidocaine
Corticosteroids
Surfactant formation for the baby
Injection within 2 days before birth
Epigastric Pain (aura for seizure)
Grand mal
With loss of consciousness
Tonic-clonic
Delivery: CS
Given epidural if NSD to anesthesize prevent seizures
Greatest risk for convulsion
1st 24 hours after delivery because of loss of fluid increased BP to
compensate for the fluid loss
ECLAMPSIA
Grand mal (generalized tonic clonic seizure w/ loss of consciousness)
Stages
Invasion
When VS is fluctuating, restless
Aura (warning) epigastric pain! (may signal HELLPS hemolysis,
elevated liver enzymes (DIC), decreased platelet)
Protect the tongue
Side-lying position (DO THIS FIRST!)
Tongue depressor is NOT safe, use mouth gag
Tongue blade (rubber)
Tonic-clonic/Contraction
20 sec tonus (muscle contraction) before clonus (alternate
contraction and relaxation)
Prevent self inflicted injuries: Time the duration of seizure to know
how much time brain lost oxygenation
Lock jaw
Prepare for safe environment; padded side rails
Do not restrain or stop
Post-ictal
Coma/Resuscitation
Oxygen first before suction

Reorient the client to prevent anxiety which may cause another

seizure
Antianxiety medication (Valium)
*Status epilipticus may cause death
Nursing Care
Mild preeclampsia

Bed rest on the left side

Diet alteration
Monitor for fetal status
Sever preeclampsia
Bed rest
Anticonvulsant medication
Fluid and electrolyte replacement
Corticosteroids are given: bethamethasone to inc surfactant
production
antiHPN meds
Mgt: Forceps assisted, analgesia to prevent stimulation
GESTATIONAL DIABETES
Human placental lactogen (HPL) counteract effect of insulin
Estrogen and progesterone antagonist of insulin
Placental insulinase enhances degradation of insulin
Placental insufficiency Maternal insulin utilization
Effect on baby
Macrosomia wide shoulders, fractured clavicle
Organomegaly heart, liver
Preterm delivery
Hypoglycemia due to hyperinsulinism inside the mother
Effect on mother
More prone to infection; UTI sugar is increase in urine
Greater incidence of PIH and eclampsia
Inc incidence of hydramnios
Distocia CS management
Atony of uterus after delivery - hemorrhage
Dx:
Not diagnosed in the 1st trimester
Diagnosed in 2nd trimester- 5th month
OGTT (glucose challenge)
Ability to use glucose in the body
Get FBS baseline; if abnormal, patient is diabetic
Intake of 50 gms of oral glucose
Check blood glucose 1 hour after
<7.8mmol, 140 mg/dl or less 7.8 mmol of less - normal
>7.8, 140- abnormal
If abnormal, ingest 100 gms of oral glucose
Check blood glucose 3 times for every hour
2 positive- (+) for GDM
Management
Only INSULIN is given 2nd trimester
Later half of pregnancy more insulin requirement
No OHA
Crosses placental barrier, teratogenic
Further aggravate insulin production in baby
Insulin
Last trimester (increased demand)
Labor- will have insulin pump
Postpartum- at risk for hypoglycemia
Postpartum- 6 weeks, diabetes should resolve
Diet: 6 meals- because of insulin to prevent hypoglycemia
200 calories additional in GDM, in normal 300cal
45- CHO
35- protein - delays absorption of glucose
20- fat
Eat a light meal before exercising
Returns to pre-pregnancy state after 6 months
CARDIAC DISEASES IN PREGNANCY
3rd trimester- risk of CHF
Decreased blood to the baby premature by size and age
If employed, advise to be shifted at day shift best time to sleep at
night during sleeping, increase growth hormones
Effects of Pregnancy on a Client with Cardiac Disease
Cardiac output increases by 30-50% CR increased by 10bmp
Progesterone stimulates the respiratory center causing dyspnea
Increase blood volume may precipitate CHF
Classes
Class 1
Asymptomatic
Rest between activities
Class 2
Asymptomatic at rest
Exertion produces symptom
Rest between activities
1 day complete bed rest per week
Allows the heart on day to recover
Last trimester- CBR
Class 3
Less than ordinary activities produce symptom
Diet: minimal carb and protein intake, low fat, low sodium
Class 4
Symptomatic even at rest

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X for pregnancy
Candidates for ligation
Managed like 3rd classification

Effects of cardiac disease on pregnancy

LBW baby due to decrease placental perfusion
If taking anticoagulant could be teratogenic
May cause premature labor and delivery

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Management
Digitalis
Propanolol
Spironolactone
Need potassium for heart contractility
Penicillin
Prophylaxis for upper respiratory tract infection caused by GABHS
sequela is rheumatic heart disease
Delivery: CS or NSD(epidural anesthesia)
Best: forceps!! Like PIH
Most critical time: 1st 24 hours
w/o for tachycardia
TORCH INFECTIONS
TOXOPLASMOSIS
Caused by parasite/protozoa
Can be ingested - Infected meat of animals (not well cooked)
From droppings of animals - Droppings of cat feces
From unpasteurized milk
Fetal effects:
Fetal hydrocephaly
Chorioretinitis
Cebrebral calcification
May cause repeated abortion
Management
Cook food very well
Antibiotics Sulfa drug (terratogenic effects noted after treatment is
given)
Abortion is an option
Complication
Can infect brain of mom and baby
Prevention
Eat only well cooked meat, do not touch cat litter

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OTHERS
Chickenpox
Hepatitis B
Transferred through placenta or breastfeeding
Mommy can breastfeed because there are immunoglobulins that can
be given to baby before feeding
RUBELLA
Congenital rubella syndrome
Congenital cataract
Glaucoma
Microcephaly
Mental retardation
PDA
Deafness damage to 8th cranial nerve
IUGR
Vaccine not given in pregnancy
Greater than 1:8 has antibodies to rubella; has immunity
Give gamma globulin; not the vaccine

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CYTOMEGALOVIRUS
Infection of the genital tract without symptoms
Infects babys brain and damage developing bone structures
Fetal effects:
Microcephaly
Cerebral calcification
Chorioretinitis
Hepatosplenomegaly possible bleeding internally
Neonatal period
Early jauncie
Hematemesis
Melena
Hematuria
Death
Management
Antiviral (Zovirax)

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o
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Not safe in early part of pregnancy (teratogenic)

Prevention
Avoid having sex with a possible contaminated partner
Have a monogamous relationship
HERPES
Painful vesicles in the vulva and peri-anal area
Zoster - chickenplox
Simplex

Herpes Simplex 1 - Oral

Herpes Simplex 2 - Genital-dangerous for baby (anal and genital)
Resembles same lesion as syphilis (chancre-painless-syphilis)
Cauliflower like lesion that is PAINFUL
Has periods of remission and exacerbation
Complications shedding the virus: direct transmission of virus to
baby
Management: CS delivery
LABOR AND DELIVERY
Labor - series of events whereby the products are expelled
Powers of Labor
Primary power - uterine contrations (involuntary)
Protaglandin cascade
Oxytocin
Progesterone deprivation
Uterine stretched theory
Secondary power intra-abdominal pressure
Needed in 2nd and 3rd stage of labor
Early postpartum 24 hours postpartum
Late postpartum 6 months
Factors that Affect Labor
Passage
Pelvis (more important)
Assessed through pelvimetry
Hip bones (innominate bones)
Ilium, ischium and pubis, coccyx, sacrum
False Pelvis- where the uterus is
Linea terminalis- separates false pelvis from true pelvis
True Pelvis
Diagonal Conjugate
DIstrance of anterior margin of the pubic to the sacrum (pelvic inlet)
Widest anteroposterior diameter
11.5-12.5cm
True Conjugate (Vera)
From lower margin of pubis to sacrum
Less than 1.5 or 2 cm from the diagonal conjugate
Ischial Diameter (bi-ischial/inter-tuberous)
Outlet (transverse diameter)
Always greater than 8 cm
Gynecoid
Round-shaped; most ideal
Wide antero-posterior diameter
Anthropoid
Wide inlet, narrow outlet
Allows vaginal delivery through forceps
Platypelloid
Oval
Wide transverse, narrow AP diameter
Wide inlet, narrow outlet
CS delivery
Android
Pelvis that is narrow on all sides
We are all android before
Bone of women thins widens
Height less than 410
Linea Terminalis
Imaginary line that separates the false from the true pelvis
Cephalopelvic Disproportion
Babys head size is not in proportion to the maternal pelvic size
Soft tissues
Passenger
Size of the fetal head
AP diameter
Occipitomentum- 13.5
Occipitofrontal- 12
Suboccipitobragmatic- 9.5
Biparietal- 9
Bi-temporal- 8
Bimastoid- 7
Fetal attitude/habitus - degree of flexion of a part
Fetal position relation of the point of reference (denominator) to the
quadrants of the pelvic inlet, where the occiput (cephalic), buttocks
(breech), or shoulder blade(acromio) is facing
Fetal lie relationship of fetal long axis and long axis of mother
Fetal presentation part seen first the fetus that is lying in the inlet
or at the cervical os
Cephalic
Vertex (occiput) - well flexed head
Brow (sinciput) - moderately flexed head
Face - exaggerated extension of the head
Mentum chin presentation
Breech
Complete
Flexed at thighs and flexed at knees

Squatting position
Buttocks and legs are presented
Difficult to deliver because it has 2 presenting parts (compound
presentation) - CS delivery
Frank
Flexed at the thighs and extended at the knees
Head cannot flex on its way out Mariceus Maneuver attempt to
flex the head in a breech delivery
Use of Pipers forceps forceps on the chin to flex
Incomplete/Footling
Legs are extended
Single or Double footling
Shoulder
Baby is on a transverse lie

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Persistent Occiput Posterior/ Back Labor

Arrested after 45 degrees
Position: side-lying
Back rub/ sacral massage
Delivery position: side lying
Fetal Station degree of descent on the ischial spine
(-) floating
0 at the level of ischial spines
(+) engaged
Primi 1 hour per station
Multigravida 30 mins per station

The relationship between the passage and fetus

Ischial Spine
Stations

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Powers (Physiologic forces)

Primary: Uterine Contraction - involuntary; contracts due to
Hormone release
Uterine Stretch theory
Secondary: Intra-abdominal Pressure voluntary
Small amount of pushing
Done on second and third stage

o
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Duration start to end of contraction

Interval space between two contraction
Frequency start to start of each contraction
Intensity hardness of the abdomen
Assessed using tocodynamometer
Frequency and duration increases are labor progresses
Interval becomes shorter as labor progresses
Psychosocial Considerations
Fear + Anxiety = Pain
Reduce fear and anxiety
Gate Control Theory
Substantiagelatinosa
Open gate- pain
Close- no pain
To close the gate: diversion/distract the mother
Birth Center - relatives can be with the mother
LDR Room - labor delivery recovery
Water Birth - Baby is a good swimmer adjustment is faster

Position
Described the relation of the point of reference (denominator) to the
quadrants of the pelvic inlet

3 Reasons for Lithotomy Position

Use forceps
Physician intends suture
Baby is in breech position

1.
2.
3.
4.

Signs of True Labor vs. False

Location abdomen radiating to the back
Positional changes intensifies the pain (if relieved by walking, false)
Rhythm regular
Cervix dilated

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STAGES OF LABOR AND DELIVERY

Stage 1: Cervical Dilation and Effacement
Begins with true labor and ends with cervical dilatation and
effacement
Effacement first before dilation
Fully effaced- both internal and external os meet
Multipara- almost the same time for dilation and effacement
Duration: 12-18 hours for primi; 6-8 hours for multi
Prolonged Labor
Greater than 18 hours in a primi
Greater than 12 hours in a multi

Precipitate labor
faster than 3 hours
danger of laceration and head injury
May be given tocolytic (Bricanyl) can be given for women who are:
grand multi, premature babies in good position, overuse of oxytocin,
large pelvis
HYPOTONIC
Decreased intensity when
woman has entered Active
phase
At risk = multi
Tx: oxytocin
For every hour oxytocin,
there should be 1 cm
cervical dilation
If not responding CS

HYPERTONIC
Strong intensity at the start of
labor (latent phase)
There 2 sources of contraction
Cervix will not dilate
Cause fetal distress
At risk = primi
Tx: Morphine
Causes respiratory distress
-labor can progress
Why not tocolytic?? Uterus
might not contract

Pacemaker- start of contraction

Fundus
Phases of First Stage
Latent
0-3 cm
Intervals: 5-30
minutes
Duration: 30 sec
Calm, walking

Active
4-7
3-5 minutes

Transition
8-10
2-3 minutes

45-60
Irritable,
Narcissistic

60-80
Behavioral change,
may lose control

Latent Phase
Time when woman is most comfortable; not in pain
Multipara- go to the hospital agad
Primipara had lightening, after 2 weeks goes into labor
Multipara had lightening, labor the same day
Nsg Dx: Anxiety and knowledge deficit; update her of the status
Interventions:
Upright position to make the baby descend faster, deep breathing
exercise, clear liquid diet, BP q1, FHT q30
Active Phase
When the patient cant handle the pain, give pain meds
Demerol (meperidine hydrochloride)
Antidote: naloxone
Phenergan- reduce secretion
Potentiates the effect of Demerol
Get RR and FHR
Nsg Dx: Acute pain
Interventions:
Breathing: Pursed-lip breathing/accelerated breathing
Massage (effleurage) - light stroking of the abdomen
Pain relief (Demerol, Nubain) given at 5 to 6 cm
Antidote: Narcan/Naloxone
Change position
Acupressure
Hoku acupressure point- improve contraction but not increase the
pain
NPO with IVF
Left side lying
Activity: None
BR on her side
FHT q 15, BP q30
Fetal Monitoring
Early deceleration (before acme)
head compression,
no variability
continue monitoring
Late deceleration
Uteroplacental insufficiency
Fetal distress
Nsg care:
Turn off pitocin
Side-lying
Start oxygen
Call the doctor(anticipate CS)
Variable deceleration
Unstable flow of blood to baby
Cord compression due to prolapse
Beat to beat variability
Nsg care:
Stop pitocin
Oxygen before CS
Transition Phase
Ready to give birth
Primi = 1 hour; multi 10-15 mins

Fear of losing control

Accompanying symptoms of n/v, trembling of legs, pressure on
bladder and rectum, circumoral pallor
Nsg Dx: Fear of losing control
Breathing: Panting and Blowing
Stirrups
Put legs on the stirrup at the same time to prevent over stretching of
ligament, changing pressure inside the uterus
Adjust height of stirrup when she sits up for bearing down
6 strokes in perineal prep pubis, leg, leg, labia ,labia, center
Use betadine, assess allergy to protein
Intervention: help regain control, prepare delivery

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Stage 2 Fetal Stages

Starts when cervix is fully dilated and effaced ends on expulsion
6 Cardinal Movements/ 7 Mechanisms of Fetal Movement
*Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
*Restitution
Expulsion
Best position: Where mother is comfortable
Sterile drapes - 4 sterile drapes
Instruments
Needle holder
Kelly straight clamp (2)
Mayo Scissor (Not part of the basic set since it is a sharp)
Needles
Cutting- pass through areas of great resistance
Round
*Tissue forceps (not part of the basic set)
Thumb forceps
Sterile basin receptacle for placenta
Crowning- support lower part of the head (Ritgens Maneuver)
Put your finger between the neck to check of there is cord coiling
Deliver the body of the baby
Bonding
Claiming identified features that are hers
Identification identifies features that are the babys
Attachment
Rooming - in to promote bonding
For stillbirth and babys with defect
Relay news immediately
Tell mother the positive first then the negative
Break it to me gently
Cord Coil or Nuchal Cord
Multiple coil clamp and cut
Single coil - loosen

o
o
o
o
o

1.
2.
3.

o
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o
o

Stage 3: Placental Delivery

5-30 mins
Placental time (duration) - starts when fetus is expelled and ends
with placental expulsion
Signs of Separation
Uterus fundus rises in the abdomen and forms a globular-shaped
uterus (Calkins sign) 1st sign
Sudden trickle or gush of blood
Umbilical cord lengthens
After delivery, check the uterus if it is contract
To stimulate contraction
Massage the uterus
Direct stimulation of the pacemaker
After, ice
Then ergot prep (methergine)
Acts like an oxytocin
Works in 15 minutes
Increase in BP
Brandt Andrews technique - remove placenta
Credes Maneuver remove placenta with fundal push

o
o

Placenta accreta
Deep attachment of the placenta to the uterine myometrium
Hysterectomy or treatment with methotrexate to destroy the stillattached tissue may be necessary
Placenta increta deep in the myometrium; muscles of uterus
Placenta percreta in the perimetrium; beyond the muscle

Battledore Placenta
cord is marginally not centrally; no problem with oxygenation; fragile

Forceps Delivery
Two double crossed spoon like articulated blades are used to assist in
the delivery of the fetal head
Check neonate and mother after delivery for any possible injury

May have facial nerve damage, Bells Palsy

Vacuum Suction
A cap-like suction device is applied to the fetal heat to facilitate
obstruction
Assess for cerebral trauma and developing cephalhematoma
Stage 4: Postpartum
Critical 24 hours is called IMMEDIATE POSTPARTUM
Patient might bleed
Lasts for about 6 weeks but may vary involution
Puerperium
Assessment in first 24 hours
VS q15 minutes for the 1st hour
Q30 for the 2nd and 3rd hour
Q1 until 24 hours have passed or until stable
Change in BP- potential for bleeding (low)
Check fundus ever 15 mins check for atony; massage intermittently
Check the condition of the uterus every 15
Atony is the common cause of bleeding the first 24 hours
Lacerations- if not atony
Laceration of uterine artery
Bleeding is bright red
Comes out in spurts (with pressure)
Do immediate repair
Laceration in Vagina
Bright red bleeding
Slow trickle
Use pressure dressing cherries insert catheter
Cherries only for 24 hours- prevent toxic shock syndrome
Laceration in Perineum
1st degree- skin
2nd- all the way to the perennial area (muscle)
3rd- anal area affected (external)
4th- rectum included
Late: retained placental tissue; puerperal sepsis
Assess blood loss
1000ml = normal for cesarean
200-400ml = normal for NSD
More than 500 = hemorrhage
Causes in early postpartum: atony, laceration
Check bladder for distention a distended bladder pushes the uterus
out of place which may prevent contraction
Uterus must be like at the level of 5 months pregnancy which is
midway between umbilicus and symphisis
BUBBLE-HE/8-Point Assessment Tool
Breast
3rd day woman will start to release milk (colostrum)
Engorgement in 2-3 days in multipari; primi in 5 days
First time 7 mins max (primi)/ 12 mins max (multi)
Marmets technique - gently pull the nipple twice if inverted nipple
Football hold - benefits CS no pressure in abdomen
Uterus decends 1-2cm fingerbreaths per day (involution)
In 10 days, uterus is not palpable
Uterus
Firm and contracted
Fundus
After birth, midway between the umbilicus and pubis
Fundus goes down by 1-2cm (fingerbreadths) a day
About 1oth day, uterus is not palpable anymore
Bladder
First 24 hours urine = 2500-3000ml
May have dehydration; inc temp
Bowel
Give full meal even with IV
IV is only for dehydration
2 days after delivery, resume of BM
if not able to defecate (constipation) laxative or suppository
Lochia
Type
Rubra
Seros
a
Alba

Color
Red, fleshy
with clots
Pink/brown,
odorless
White,odorle
ss

Duration
1-3 days
7 days
1-3 wks

Components
Blood, fragments of
deciduas, mucus
Blood, mucus,
invading leukocytes
Largely mucus,
leukocyte count high

Episiotomy
R redness
E- edema
E ecchymosis
D discharge
A approximation
Needs order form MD, perineal prep, must be 12 inches away
8Major sign of sepsis low grade fever/chills

Homans Sign
Emotions
Reva Rubins Assessment
Taking in
Mothers
needs
predominate
I cannot do it,
you do it
Dependent
1-2 days

Taking hold
Interests, shifts to infant and
infants needs
Post partum blues (they want
babies, but they are afraid);
less than 1 week
Post partum depression
psychosis; more than 1 week
Independent

Letting go
Bursting out
Socializing
Back to work

Interdepende
nt