Obstetrics Review

ANGEL ALBERT F.
LAMBAN, RN, MD
Human Sexuality
Concepts
A persons sexuality encompasses the complex

behaviors, attitudes emotions and preferences that are
related to sexual self and eroticism
Sex basic and dynamic aspect of life
During reproductive years, the nurse performs as

resource person on human sexuality.
Definitions related to sexuality:
Gender identity sense of femininity or masculinity
2-4 yrs/3 yrs gender identity develops
Role identity attitudes, behaviors and attributes that

differentiate roles
Sex biologic male or female status. Sometimes referred to

a specific sexual behavior such as sexual intercourse.
Sexuality - behavior of being boy or girl, male or female

man/ woman. Entity life long dynamic change.
- developed at the moment of conception
Sexual Anatomy and Physiology
A. Female Reproductive System
1. External value or pretender
a. Mons pubis/veneris - a pad of fatty tissues that

lies over the symphysis pubis covered by skin and at
puberty covered by pubic hair that serves as cushion or
protection to the symphysis pubis.
Stages of Pubic Hair Development
Tannerscale tool - used to determine sexual maturity rating.
Stage 1 Pre-adolescence. No pubic hair. Fine body hair only
Stage 2 Occurs between ages 11 and 12 sparse, long, slightly

pigmented & curly hair at pubis symphysis
Stage 3 occurs between ages 12 and 13 darker & curlier at labia
Stage 4 occurs between ages 13 and 14, hair assumes the normal
appearance of an adult but is not so thick and does no appear to the
inner aspect of the upper thigh
Stage 5 sexual maturity- normal adult- appear inner aspect of upper

thigh .
b. Labia Majora - large lips longitudinal fold, extends
symphisis pubis to perineum
c. Labia Minora 2 sensitive structures

clitoris-
anterior, pea shaped erectile tissue with lots of sensitive nerve endings; sight
of sexual arousal (Greek-key)
fourchette-
Posterior, tapers posteriorly of the labia minora- sensitive to manipulation,
torn during delivery.
Site episiotomy
d. Vestibule an almond shaped area that contains the

hymen, vaginal orifice and bartholenes glands.
e. Perineum muscular structure loc lower vagina &

anus
Urinary Meatus small opening of urethra, serves for urination
Skenes glands/or paraurethral gland mucus secreting subs for

lubrication
hymen covers vaginal orifice, membranous tissue
vaginal orifice external opening of vagina
bartholenes glands - paravaginal gland or vulvo vaginal gland -2

small mucus secreting subs secretes alkaline substance
Alkaline neutralizes acidity of vagina

Ph of vagina - acidic
Doderleins bacillus responsible for acidity of vagina
Carumculae mystiformes - healing of torn hymen
2. Internal
A. vagina female organ of copulation, passageway of mens & fetus, 3 4inches or

8 10 cm long, dilated canal
Rugae permits stretching without tearing
B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in

size, shape and weights.
Size- 1x2x3
Shape: nonpregnant pear shaped / pregnant ovoid
Weight - nonpregnant 50 -60 g- pregnant 1,000g
Pregnant/ Involution of uterus:

4th stage of labor -1000g
2 weeks after delivery - 500g
3 weeks after delivery - 300 g
5-6 weeks after delivery - returns to original, state 50 60 gms
Three parts of the uterus
fundus - upper cylindrical layer
corpus/body - upper triangular layer
cervix - lower cylindrical layer
* Isthmus lower uterine segment during pregnancy

Cornua-junction between fundus & interstitial
Muscular compositions:
there are three main muscle layers which make expansion possible in every
direction.
Endometrium- inside uterus, lines the nonpregnant uterus.

Muscle layer for menstruation.
Sloughs during menstruation.
Endometriosis - proliferation of endometrial lining outside
uterus. Common site: ovary.
S/sx: dysmennorhea, low back pain.

Dx:
biopsy
Laparoscopy
Meds:
1. Danazole (Danocrene)
a. to stop mens
b. inhibit ovulation
2. Lupreulide (Lupron)
inhibit FSH/LH production
Myometrium
largest part of the uterus, muscle layer for delivery process
Its smooth muscles are considered to be the living ligature

of the body
Power of labor, resp- contraction of the uterus
Perimetrium
protects entire uterus
c. ovaries 2 female sex glands, almond shaped.
Function: 1. ovulation
2. Production of hormones
d. Fallopian tubes
2-3 inches long that serves as a passageway of the sperm
from the uterus to the ampulla or the passageway of the
mature ovum or fertilized ovum from the ampulla to the
uterus.
4 significant segments
1. Infundibulum
distal part of FT, trumpet or funnel shaped,
swollen at ovulation
2. Ampulla
outer 3rd or 2nd half, site of fertilization
3. Isthmus
site of sterilization bilateral tubal ligation
4. Interstitial
site of ectopic pregnancy most dangerous
B. Male Reproductive System
1. External
Penis
the male organ of copulation and urination. It contains of a
body of a shaft consisting of 3 cylindrical layers and erectile
tissues. At its tip is the most sensitive area comparable to that
of the clitoris in the female the glands penis.
3 Cylindrical Layers
2 corpora cavernosa
1 corpus spongiosum
Scrotum
a pouch hanging below the pendulous penis, with a medial
septum dividing into two sacs, each of which contains a testes.
cooling mechanism of testes

< 2 degrees C than body temp.
Leydig cell release testosterone
2. Internal
The Process of Spermatogenesis maturation of sperm

Male and Female homologues
Male Female
Penile glans Clitoral glans

Penile shaft Clitorial shaft
Testes Ovaries
Prostate Skenes gands
Cowpers Glands Bartholin's glands
Scrotum Labia Majora
III. Basic Knowledge on Genetics and Obstetrics
DNA
carries genetic code
Chromosomes
threadlike strands composed of hereditary material DNA
Normal amount of ejaculated sperm
3 5 cc., 1 tsp
Ovum is capable of being fertilized with in 24 36 hrs after
ovulation
Sperm is viable within 48 72 hrs, 2-3 days
Reproductive cells divides by the process of meiosis
(haploid)
Spermatogenesis
maturation of sperm
Oogenesis
maturation of ovum
Gematogenesis
formation of 2 haploid into diploid 23 + 23 = 46 or diploid
Age of Reproductivity 15 44yo
Menstrual Cycle
beginning of mens to beginning of next mens
Average Menstrual Cycle 28 days
Average Menstrual Period 3 5 days
Normal Blood loss 50cc or cup
Related terminologies:
Menarche 1st mens
Dysmenorrhea painful mens
Metrorrhagia bleeding between mens

Menorhagia excessive during mens
Amenorrhea absence of mens
Menopause cessation of mens/ average :
51 years old
* Estrogen Hormone of the Woman
Primary function: development secondary sexual characteristic

female.
Others:
inhibit production of FSH ( maturation of ovum)

hypertrophy of myometrium
Spinnbarkeit & Ferning ( billings method/ cervical)
development ductile structure of breast
increase osteoblast activities of long bones
increase in height in female
causes early closure of epiphysis of long bones
causes sodium retention
increase sexual desire
*Progestin Hormone of the Mother
Primary function: prepares endometrium for implantation of

fertilized ovum making it thick & tortous
Secondary Function: uterine contractility (favors

pregnancy)
Others:
inhibit prod of LH (hormone for ovulation)
inhibit motility of GIT
mammary gland development
increase permeability of kidney to lactose & dextrose causing (+)
sugar
causes mood swings in moms
increase BBT
Menstrual Cycle
4 Phases of Menstrual Cycle
1. Proliferative
2. Secretory
3. Ischemic
4. Menses
Parts of body responsible for mens:
hypothalamus
anterior pituitary gland master clock of body
ovaries
uterus
Initial phase 3rd day decreased estrogen
13th day peak estrogen, decrease progesterone
14th day Increase estrogen, increase progesterone
15th day Decrease estrogen, increase progesterone

On the initial 3rd phase of menstruation , the estrogen
level is decreased, this level stimulates the
hypothalamus to release GnRH or FSHRF
GnRH/FSHRF stimulates the anterior pituitary gland
to release FSH
Functions of FSH:
Stimulate ovaries to release estrogen
Facilitate growth primary follicle to become graffian follicle

(secretes large amt estrogen & contains mature ovum.)
Proliferative Phase
proliferation of tissue or follicular phase,
post mens phase.
Pre-ovulatory.
-phase of increase estrogen.

Follicular Phase causing irregularities of mens
Postmenstrual Phase
Preovulatory Phase phase increase estrogen
Proliferative Phase
13th day of menstruation, estrogen level is peak while the

progesterone level is down, these stimulates the
hypothalamus to release GnRF on LHRF
Mittelschmerz slight abdominal pain on L or RQ of

abdomen, marks ovulation day.
Change in BBT, mood swing
GnRF/LHRF stimulates the ant pit gland to release LH.

Proliferative Phase
Functions of LH:
(13th day-decreased progesterone) LH stimulates ovaries
to release progesterone hormone for ovulation
14th day estrogen level is increased while the

progesterone level is increased causing rupture of
graffian follicle on process of ovulation.
15th day, after ovulation day, graafian follicle starts to

degenerate yellowish known as corpus luteum (secrets
large amount of progesterone)
Secretory Phase
Lutheal Phase
Postovulatory PhaseIncreased progesterone
Premenstrual Phase
24th day if no fertilization, corpus luteum degenerate

( whitish corpus albicans)
28th day if no sperm in ovum endometrium begins to

slough off to begin mens
Secretory Phase
Cornix- where sperm is deposited
Sperm- small head, long tail, pearly white
Phonones-vibration of head of sperm to determine

location of ovum
Sperm should penetrate corona radiata and zona pellocida.
Capacitation- ability of sperm to release proteolytic

enzyme to penetrate corona radiata and zona pellocida.
Stages of Sexual Responses (EPOR)
Initial responses:
Vasocongestion congestion of blood vessels

Myotonia increase muscle tension
Excitement Phase
(sign present in both sexes, moderate increase in HR, RR,BP,
sex flush, nipple erection) erotic stimuli cause increase
sexual tension, lasts minutes to hours.
Plateau Phase
(accelerated V/S) increasing & sustained tension nearing
orgasm. Lasts 30 seconds 3 minutes.
Stages of Sexual Responses (EPOR)
Orgasm
(involuntary spasm throughout body, peak v/s) involuntary
release of sexual tension with physiologic or psychologic
release, immeasurable peak of sexual experience. May last 2
10 sec- most affected are is pelvic area.
Resolution
(v/s return to normal, genitals return to pre-excitement
phase)
Refractory Period
the only period present in males, wherein he cannot be
restimulated for about 10-15 minutes
Fertilization
Stages of Fetal Growth and

Development
3-4 days travel of zygote

mitotic cell division begins
Fertilization
A. Pre-embryonic Stage
a. Zygote
- fertilized ovum.
Lifespan of zygote from fertilization to 2 months
b. Morula
mulberry-like ball with 16 50 cells,
4 days free floating & multiplication
c. Blastocyst
enlarging cells that forms a cavity that later becomes the embryo.
covering of blastocys that later becomes placenta & trophoblast
d. Implantation/ Nidation- occurs after fertilization 7 10 days.

Fertilization
B. Fetus
- 2 months to birth.
placenta previa implantation at low side of uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization corpus luteum continues to function &

become source of estrogen & progesterone while placenta is
not developed.
Fertilization
3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion
C. Decidua thickened endometrium ( Latin falling
off)
Basalis (base) part of endometrium located under
fetus where placenta is delivered
Capsularies encapsulate the fetus
Vera remaining portion of endometrium.
D. Chorionic Villi- 10 11th day, finger life projections

3 vessels=
A unoxygenated blood
V O2 blood
A unoxygenated blood
Whartons jelly protects cord
Chorionic villi sampling (CVS)

removal of tissue sample from the fetal portion of the
developing placenta for genetic screening
Done early in pregnancy
Common complication fetal limb defect.

Ex missing digits/toes.
E. Cytotrophoblast
inner layer or langhans layer
protects fetus against syphilis 24 wks/6 months
life span of langhans layer increase.
- Before 24 weeks critical, might get infected syphilis
F. Syncitiotrophoblast
synsitial layer
responsible production of hormone
1. Amnion inner most layer

a. Umbilical Cord
whitish grey, 15 55cm, 20 21
Short cord: abruptio placenta or inverted uterus

Long cord:cord coil or cord prolapse
b. Amniotic Fluid
bag of H2O, clear, odor mousy/musty, with crystallized
forming pattern, slightly alkaline.
*Function of Amniotic Fluid:
1. cushions fetus against sudden blows or trauma
2. facilitates musculo-skeletal development
3. maintains temp
4. prevent cord compression
5. help in delivery process
normal amt of amniotic fluid 500 to 1000cc
polyhydramnios, hydramnios
- GIT malformation TEF/TEA, increased amt of fluid
oligohydramnios
- decrease amt of fluid kidney disease
Diagnostic Tests for Amniotic Fluid
A. Amniocentesis
empty bladder before performing the procedure.
Purpose
obtain a sample of amniotic fluid by inserting a needle
through the abdomen into the amniotic sac;
fluid is tested for:
Genetic screening
- maternal serum alpha feto-protein test
(MSAFP)
- Determination of fetal maturity primarily by
evaluating factors indicative of lung maturity
Testing time
36 weeks
decreased MSAFP
= down syndrome
increase MSAFP
= spina bifida or open neural tube defect
Common complication of amniocentesis

infection
Dangerous complications
spontaneous abortion
3rd trimester
- pre term labor
Important factor to consider for amniocentesis

- needle insertion site
Aspiration of yellowish amniotic fluid jaundice baby
Greenish meconium
Amnioscopy
direct visualization or exam to an intact fetal membrane.
Fern Test
- determine if amniotic fluid has ruptured or not
- blue paper turns green/grey - + ruptured amniotic fluid
Nitrazine Paper Test

- diff amniotic fluid & urine.
- Paper turns yellow- urine.
- Paper turns blue green/gray-(+) rupture of amn fluid.
Chorion
where placenta is developed
Lecithin Sphingomyelin L/S

Ratio- 2:1 signifies fetal lung maturity not capable for
RDS
Phosphatidylglycerol
: PG+ definitive test to determine fetal lung maturity
Placenta
(Secundines) Greek
pancake, combination of chorionic villi +

deciduas basalis.
- Size: 500g or kg
-1 inch thick & 8 diameter

Functions of Placenta:
Respiratory System
beginning of lung function after birth of baby.
Simple diffusion
GIT
transport center, glucose transport is facilitated, diffusion more
rapid from higher to lower.
If mom hypoglycemic, fetus hypoglycemic
Excretory System
- artery - carries waste products.
Liver of mom detoxifies fetus.
Circulating system
achieved by selective osmosis
Endocrine System produces hormones
Human Chorionic Gonadrophin

maintains corpus luteum alive.
Human placental Lactogen or
sommamommamotropin Hormone
for mammary gland development.
Has a diabetogenic effect serves as insulin
antagonist
Relaxin Hormone- causes softening joints & bones
estrogen
progestin
It serves as a protective barrier against some

microorganisms HIV,HBV
Fetal Stage Fetal Growth and Development
Entire pregnancy days 266 280 days 37 42 weeks
Differentiation of Primary Germ layers
Endoderm
1st week endoderm primary germ layer
Thyroid for basal metabolism
Parathyroid - for calcium
Thymus development of immunity
Liver lining of upper RT & GIT
Mesoderm
development of heart, musculoskeletal
system, kidneys and repro organ
Ectoderm
development of brain, skin and senses, hair,
nails, mucus membrane or anus & mouth
First trimester:
1st month
Brain & heart development
GIT& resp Tract remains as single tube
1. Fetal heart tone begins heart is the oldest part of the

body
2. CNS develops dizziness of mom due to
hypoglycemic effect
Food of brain glucose complex CHO pregnant
women food (potato)
First trimester:
Second Month
All vital organs formed, placenta developed
Corpus luteum source of estrogen &
progesterone of infant life span end of 2nd
month
Sex organ formed
Meconium is formed
First trimester:
Third Month
Kidneys functional
Buds of milk teeth appear
Fetal heart tone heard Doppler 10 12 weeks
Sex is distinguishable
Second trimester:
FOCUS length of fetus
Fourth Month
lanugo begins to appear
fetal heart tone heard fetoscope, 18 20 weeks
buds of permanent teeth appear
Second trimester:
Fifth Month
lanugo covers body
actively swallows amniotic fluid
19 25 cm fetus,
Quickening- 1st fetal movement. 18- 20 weeks primi, 16-
18 wks multi
fetal heart tone heard with or without instrument
Second trimester:
Sixth Month
eyelids open
wrinkled skin
vernix caseosa present
Third trimester:
Period of most rapid growth. FOCUS: weight of fetus
Seventh Month
development of surfactant lecithin
Eighth Month
lanugo begin to disappear
sub Q fats deposit
Nails extend to fingers
Third trimester:
Ninth Month
lanugo & vernix caseosa completely disappear
Amniotic fluid decreases
Tenth Month
bone ossification of fetal skull
Terratogens
any drug, virus or irradiation, the exposure to such may
cause damage to the fetus
Drugs:
Streptomycin anti TB & or Quinine (anti malaria)
damage to 8th cranial nerve poor hearing & deafness
Tetracycline staining tooth enamel, inhibit growth of
long bone
Vitamin K hemolysis (destr of RBC), hyperbilirubenia
or jaundice
Iodides enlargement of thyroid or goiter
Thalidomides Amelia or pocomelia, absence of
extremities
Steroids cleft lip or palate
Lithium congenital malformation
Alcohol lowered weight (vasoconstriction on mom), fetal

alcohol withdrawal syndrome char by microcephaly
Smoking low birth rate
Caffeine low birth rate
Cocaine low birth rate, abruption placenta

TORCH (Terratogenic) Infections viruses
CHARACTERISTICS
group of infections caused by organisms that can cross the placenta or
ascend through birth canal and adversely affect fetal growth and
development
These infections are often characterized by vague, influenza like

findings, rashes and lesions, enlarged lymph nodes, and jaundice
(hepatic involvement)
In some chases the infection may go unnoticed in the pregnant woman

yet have devastating effects on the fetus
TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes

simples virus.
T toxoplasmosis
mom takes care of cats.
Feces of cat go to raw vegetables or meat
O others.
Hepa A or infectious heap oral/ fecal (hand washing)
Hepa B, HIV blood & body fluids
Syphilis
R rubella
German measles
congenital heart disease (1st month) normal rubella
titer 1:10
<1:10 less immunity to rubella, after delivery, mom will be
given rubella vaccine. Dont get pregnant for 3
months. Vaccine is terratogenic
C cytomegalo virus
H herpes simplex virus

Physiological Adaptation of the Mother to Pregnancy
A. Systemic Changes
1. Cardiovascular System
increase blood volume of mom (plasma blood) 30

50% = 1500 cc of blood
- easy fatigability, increase heart workload, slight
hypertrophy of ventricles, epistaxis
due to hyperemia of nasal membrane palpitation,
Physiologic Anemia pseudo anemia of pregnant women

A. Systemic Changes
Normal Values
Hct 32 42%
Hgb 10.5 14g/dL
Criteria
1st and 3rd trimester.
- pathologic anemia if lower,
HCT should not be 33%,
Hgb should not be < 11g/dL
2nd trimester
Hct should not <32%
- Hgb Shdn't < 10.5% pathologic anemia if lower
Pathologic Anemia
iron deficiency anemia is the most common hematological

disorder. It affects toughly 20% of pregnant women.
- Assessment reveals:
Pallor, constipation
Slowed capillary refill
Concave fingernails (late sign of progressive anemia)
due to chronic physio hypoxia
Pathologic Anemia
Nursing Care:
Nutritional instruction kangkong, liver due to
ferridin content, green leafy vegetable-
alugbati,saluyot, malunggay, horseradish, ampalaya
Parenteral Iron ( Imferon) severe anemia, give IM, Z

tract- if improperly administered, hematoma
Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a

day) empty stomach 1 hr before meals or 2 hrs after,
black stool, constipation
Monitor for hemorrhage

Pathologic Anemia
Alert:
Iron from red meats is better absorbed iron form other
sources
Iron is better absorbed when taken with foods high in

Vit C such as orange juice
Higher iron intake is recommended since circulating

blood volume is increased and heme is required from
production of RBCs
Edema
lower extremities due venous return is constricted due to

large belly, elevate legs above hip level.
Varicosities pressure of uterus

use support stockings, avoid wearing knee high socks
use elastic bandage lower to upper
Vulvar varicosities- painful, pressure on gravid uterus,

to relieve- position side lying with pillow under hips or
modified knee chest position
Thrombophlebitis presence of thrombus at inflamed
blood vessel
pregnant mom hyperfibrinogenemia
increase fibrinogen
increase clotting factor
thrombus formation candidate
outstanding sign (+) Homan's sign pain on calf during

dorsiflexion
milk leg skinny white legs due to stretching of skin

caused by inflammation or phlagmasia albadolens
Edema
Mgt:
Bed rest
Never massage
Assess + Homan sign once only might dislodge
thrombus
Give anticoagulant to prevent additional clotting
(thrombolytics will dilute)
Monitor APTT antidote for Heparin toxicity, protamine
sulfate
Avoid aspirin! Might aggravate bleeding.
Respiratory system common problem SOB due to enlarged uterus &
increase O2 demand
Position- lateral expansion of lungs or side lying position.
Gastrointestinal 1st trimester change
Morning Sickness nausea & vomiting due to increase HCG.

Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea
afternoon
small freq feeding.
Vomiting in pregnancy hyperemesis gravidarum
Metabolic alkalosis, F&E imbalance primary med mgt replace

fluids.
Monitor I&O
constipation progesterone resp for constipation
Increase fluid intake, increase fiber diet

- fruits papaya, pineapple, mango, watermelon,
cantaloupe, apple with skin, suha.
Except guava has pectin thats constipating veg

petchy, malungay.
- exercise
-mineral oil excretion of fat soluble vitamins
* Flatulence avoid gas forming food cabbage

* Heartburn or pyrosis reflux of stomach content to
esophagus
- small frequent feeding, avoid 3 full meals, avoid fatty

& spicy food, sips of milk, proper body mechanical
increase salivation ptyalsim mgt mouthwash
*Hemorrhoids pressure of gravid uterus.

Mgt; hot sitz bath for comfort
Urinary System
frequency during 1st & 3rd trimester lateral expansion of lungs or
side lying pos
mgt for nocturia
Acetyace test albumin in urine
Benedicts test sugar in urine
Musculoskeletal
Lordosis pride of pregnancy
Waddling Gait awkward walking due to relaxation causes softening
of joints & bones
Prone to accidental falls wear low heeled shoes
Leg Cramps
causes: prolonged standing, over fatigue, Ca &
phosphorous imbalance(#1 cause while pregnant), chills,
oversex, pressure of gravid uterus (labor cramps) at lumbo
sacral nerve plexus
Management|:
Increase Ca diet-milk(Inc Ca & Inc phosphorus)-
1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish,
Dilis, sardines with bones, brocolli, seafood-tahong
(mussels), lobster, crab.
Vit D for increased Ca absorption

B. Local Changes
Local change: Vagina:
V Chadwicks sign
blue violet discoloration of vagina
C Goodel's sign
change of consistency of cervix
I Hegar's
change of consistency of isthmus (lower uterine
segment)
B. Local Changes
LEUKORRHEA whitish gray, mousy odor discharge
ESTROGEN hormone, resp for leucorrhea
OPERCULUM mucus plug to seal out bacteria.
PROGESTERONE hormone responsible for operculum
PREGNANT acidic to alkaline change to protect

bacterial growth (vaginitis)
Problems Related to the Change of Vaginal Environment:
Vaginitits trichomonas vaginalis due to alkaline environment of

vagina of pregnant mom
Flagellated protozoa wants alkaline
S&Sx:
Greenish cream colored frothy irritatingly itchy with foul smelling
odor with vaginal edema
Mgt:
FLAGYL (metronidazole antiprotozoa).
Carcinogenic drug so dont give at 1st trimester
treat dad also to prevent reinfection
no alcohol has antibuse effect
VAGINAL DOUCHE IQ H2O : 1 tbsp white vinegar
Problems Related to the Change of Vaginal Environment:
Moniliasis or candidiasis due to candida albecans, fungal

infection.
Color white cheese like patches adheres to walls of vagina.
Signs & Symptoms:

Management antifungal Nistatin, genshan violet,
cotrimaxole, canesten
Gonorrhea -Thick purulent discharge
Vaginal warts- condifoma acuminata due to papilloma virus
Mgt:
cauterization
Abdominal Changes
striae gravidarium (stretch marks) due enlarging
uterus-destruction of sub Q tissue
avoid scratching, use coconut oil, umbilicus is
protruding
Skin Changes
brown pigmentation nose chin, cheeks
chloasma melasma due to increased melanocytes.
Brown pinkish line- linea nigra- symphisis pubis to
umbilicus
Breast Changes
increase hormones, color of areola & nipple
pre colostrums present by 6 weeks, colostrums at 3rd
trimester
Breast self exam

7 days after mens
supine with pillow at back
quadrant B upper outer common site of cancer
Presumptive
Breast changes
Urinary freq
Fatigue
Amenorrhea
Morning sickness
Enlarged uterus
Chloasma
Linea negra
Increased skin pigmentation
Striae gravidarium
Quickening
Probable
Goodel's- change of consistency of cervix

Chadwicks- blue violet discoloration of vagina
Hegar's- change of consistency of isthmus
Elevated BBT due to increased progesterone
Positive HCG or (+)preg test
Ballottement bouncing of fetus when lower uterine is

tapped sharply
Enlarged abdomen
Braxton Hicks contractions painless irregular
contractions
Positive
Ultrasound evidence (sonogram) full bladder
Fetal heart tone

Fetal movement
Fetal outline
Fetal parts palpable
Test to determine breast cancer:
1. mammography 35 to 49 yrs once every 1 to 2 yrs

50 yrs and above 1 x a yr
Ovaries rested during pregnancy
Signs & symptoms of Pregnancy

Presumptive s/s felt and observed by the mother but does
not confirm positive diagnosis of pregnancy . Subjective
Probable signs observed by the members of health team.

Objective
Positive Signs undeniable signs confirmed by the use of

instrument.
Ballotment sign of myoma
* + HCG sign of H mole
- trans vaginal ultrasound. Empty bladder
- ultrasound full bladder
placental grading rating/grade

o immature
1 slightly mature
2 moderately mature
3 placental maturity
Psychological Adaptation to Pregnancy
(Emotional response of mom Reva Rubin theory)
First Trimester: No tangible signs & sx,

surprise, ambivalence, denial sign of maladaptation to pregnancy.
Developmental task is to accept biological facts of pregnancy
Focus: bodily changes of preg, nutrition
Second Trimester tangible S&Sx.

mom identifies fetus as a separate entity due to presence of
quickening, fantasy.
Developmental task accept growing fetus as baby to be nurtured.
Health teaching: growth & development of fetus.
Psychological Adaptation to Pregnancy
Third Trimester: - mom has personal identification on

appearance of baby
Development task: prepare of birth & parenting of child.

HT: responsible parenthood babys Layette best time to
do shopping.
Most common fear let mom listen to FHT to allay fear

Lamaze classes
Pre-Natal Visit:
1. Frequency of Visit:
1st 7 months 1x a month
8 9 months 2 x a month
10 once a week
post term 2 x a week
2. Personal data
name, age (high risk < 18 & >35 yrs old) record to
determine high risk HBMR.
Home base moms record. Sex ( pseudocyesis or false
pregnancy on men & women)
Couvade syndrome dad experiences what mom goes through
lihi)
Address, civil status, religion, culture & beliefs with respect,
non judgmental
Occupation financial condition or occupational hazards,
education background level knowledge
3. Diagnosis of Pregnancy
urine exam to detect HCG at 40 100th day. 60 70 day
peak HCG. 6 weeks after LMP- best to get urine exam.
Elisa test test for preg detects beta subunit of HCG as
early as 7 10days
Home preg kit do it yourself
4. Baseline Data: V/S esp. BP, monitor wt. (increase wt 1st
sign preeclampsia)
Weight Monitoring
First Trimester:
Normal Weight gain 1.5 3 lbs (.5 1lb/month)
Second trimester:
normal weight gain 10 12 lbs (4 lbs/month)
(1 lb/wk)
Third trimester:
normal weight gain 10 12 lbs (4 lbs/ month)
( 1lb/wk)
Minimum wt gain 20 25 lbs
Optimal wt gain 25 35 lbs

5. Obstetrical Data:
nullipara no pregnancy
Gravida- # of pregnancy
Para - # of viable pregnancy
Viability the ability of the fetus to live outside the

uterus at the earliest possible gestational age.
age of viability 20 24 wks

Term 37 42 wks,
Preterm 20 37 weeks
abortion <20 weeks
Important Estimates:
Nageles Rule use to determine expected date of delivery
Get LMP -3+ 7 +1 Apr-Dec LMP Jan Feb Mar

M D Y +9 +7 no year
LMP Jan 25, 04

+9 +7
10 / 32 / 04
- 1
add 1 month to month
11/31/04 EDD
McDonalds Rule to determine age of gestation IN
WEEKS
FUNDIC HT X 7/8=AOG in WK
From symphysis pubis to fundus

Bartholomews Rule to determine age of gestation
by proper location of fundus at abdominal cavity.
3 months above sym pub

5 months level of umbilicus
9 months below xiphoid
10 months level of 8 months due to lightening
Haases rule to determine length of the fetus in cm.
Formula: 1st of preg , square @ month
2nd of preg, x @ month by 5
3mos x 3 = 9cm
4 mos x 4 = 16 cm 1st of preg
5 x 5 = 25 cm
6 x 5 = 30 cm
7 x 5 = 35 cm 2nd of preg
8 x 5 = 40 cm
9 x 5 = 45 cm
tetanus immunizations prevents tetanus neonatum
-mom with complete 3 doses DPT young age considered as TT1 & 2.
Begin TT3
TT1 any time during pregnancy
TT2 4 wks after TT1 3 yrs protection
TT3 6 months after TT2 5 yrs protection
TT4 1 yr after TT3 10 yrs protection
TT5 yr after TT4 lifetime protection

Physical Examination:
A. Examine teeth: sign of infection
Danger signs of Pregnancy
C - chills/ fever infection

Cerebral disturbances ( headache preeclampsia)
A abdominal pain ( epigastric pain aura of

impending convulsions
Danger signs of Pregnancy
B boardlike abdomen abruption placenta

Increase BP HPN
Blurred vision preeclampsia
Bleeding 1st trimester, abortion, ectopic pre/2nd H
mole, incompetent cervix
3rd placental anomalies
S sudden gush of fluid PROM (premature rupture of

membrane) prone to inf.
E edema to upper ext. (preeclampsia)

Pelvic Examination internal exam
empty bladder
universal precaution
EXT OS of cervix site for getting specimen
Site for cervical cancer
Pap Smear cervical cancer

- composed of squamous columnar tissue
Result:
Class I normal
Class IIA acytology but no evidence of malignancy

B suggestive of infl.
Class III cytology suggestive of malignancy
Class IV cytology strongly suggestive of malignancy
Class V cytology conclusive of malignancy

Stages of Cervical Cancer
Stage
0 carcinoma insitu
1 cancer confined to cervix
2 - cancer extends to vagina
3 pelvis metastasis
4 affection to bladder & rectum

7. Leopolds Maneuver
Purpose: is done to determine the attitude, fetal
presentation lie, presenting part, degree of descent, an
estimate of the size, and number of fetuses, position,
fetal back & fetal heart tone
- use palm! Warm palm.
Prep mom:
Empty bladder
Position of mom-supine with knee flex (dorsal
recumbent to relax abdominal muscles)
Procedure:
1st maneuver: place patient in supine position with

knees slightly flexed; put towel under head and right
hip; with both hands palpate upper abdomen and
fundus. Assess size, shape, movement and firmness of
the part to determine presentation
2nd Maneuver: with both hands moving down, identify

the back of the fetus ( to hear fetal heart sound) where
the ball of the stethoscope is placed to determine FHT.
Get V/S(before 2nd maneuver) PR to diff fundic souffl
(FHR) & uterine souffl.
Uterine souffl maternal H rate
Procedure:
3rd Maneuver: using the right hand, grasp the symphis pubis
part using thumb and fingers.
To determine degree of engagement.
Assess whether the presenting part is engaged in the pelvis
Alert : if the head is engaged it will not be movable).
4th Maneuver: the Examiner changes the position by facing

the patients feet. With two hands, assess the descent of the
presenting part by locating the cephalic prominence or brow.
To determine attitude relationship of fetus to 1 another.
When the brow is on the same side as the back, the head is
extended.
When the brow is on the same side as the small parts, the
head will be flexed and vertex presenting.
Attitude relationship of fetus to a part or degree of

flexion
Full flexion when the chin touches the chest

8.Assessment of Fetal Well-Being
Daily Fetal Movement Counting (DFMC)

begin 27 weeks
Mom- begin after meal breakfast
a. Cardiff count to 10 method one method currently

available
(1) Begin at the same time each day (usually in the morning,
after breakfast) and count each fetal movement, noting how
long it takes to count 10 fetal movements (FMs)
(2) Expected findings 10 movements in 1 hour or less

Warning signs
a.) more then 1 hour to reach 10 movements

b.) less then 10 movements in 12 hours(non-reactive- fetal
distress)
c.) longer time to reach 10 FMs than on previous days
d.) movement are becoming weaker, less vigorous
Movement alarm signals - < 3 FMs in 12 hours
warning signs should be reported to healthcare provider

immediately; often require further testing.
Examples: nonstress test (NST), biophysical profile (BPP)
Nonstress test to determine the response of the fetal heart
rate to activity
Indication pregnancies at risk for placental insufficiency

Postmaturity
pregnancy induced hypertension (PIH), diabetes
warning signs noted during DFMC
maternal history of smoking, inadequate nutrition
Procedure:
Done within 30 minutes wherein the mother is in semi-

fowlers position (w/ fetal monitor); external monitor is
applied to document fetal activity; mother activates the mark
button on the electronic monitor when she feels fetal
movement.
Attach external noninvasive fetal monitors
tocotransducer over fundus to detect uterine contractions

and fetal movements (FMs)
ultrasound transducer over abdominal site where most

distinct fetal heart sounds are detected
monitor until at least 2 FMs are detected in 20 minutes
if no FM after 40 minutes provide woman with a light

snack or gently stimulate fetus through abdomen
if no FM after 1 hour further testing may be indicated,
such as a CST
Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good
Interpretation of results
Reactive result
Baseline FHR between 120 and 160 beats per minute
At least two accelerations of the FHR of at least 15 beats per

minute, lasting at least 15 seconds in a 10 to 20 minute period as a
result of FM
Good variability normal irregularity of cardiac rhythm

representing a balanced interaction between the parasympathetic
(decreases FHR) and sympathetic (increase FHR) nervous system;
noted as an uneven line on the rhythm strip
result indicates a healthy fetus with an intact nervous system

Interpretation of results
Nonreactive result
Stated criteria for a reactive result are not met

Could be indicative of a compromised fetus.
Requires further evaluation with another NST,
biophysical profile, (BPP) or contraction stress test
(CST)
9. Health teachings
Nutrition do nutritional assessment daily food intake

High risk moms:
Pregnant teenagers low compliance to heath regimen
Extremes in wt underweight, over wt candidate for HPN,

DM
Low socio economic status
Vegetarian mom decrease CHON

needs Vit B12 cyanocobalamin formation of folic acid
needed for cell DNA & RBC formation.
(Decrease folic acid spina bifida/open neural tube defect)
Recommended Nutrient Requirement that
increases During Pregnancy
Calories
Nutrients
Essential to supply energy for

increased metabolic rate
utilization of nutrients
protein sparing so it can be used for
Growth of fetus
Development of structures required for pregnancy
including placenta, amniotic fluid, and tissue growth.
Calories
Requirements
300 calories/day above the prepregnancy daily requirement

to maintain ideal body weight and meet energy
requirement to activity level
Begin increase in second trimester
Use weight gain pattern as an indication of adequacy of
calorie intake.
Failure to meet caloric requirements can lead to ketosis as fat
and protein are used for energy; ketosis has been associated
with fetal damage.
Calories
Food Source
Caloric increase should reflect

Foods of high nutrient value such as protein, complex
carbohydrates (whole grains, vegetables, fruits)
Variety of foods representing foods sources for the nutrients
requiring during pregnancy
No more than 30% fat
Protein
Nutrients
Essential for:
Fetal tissue growth
Maternal tissue growth including uterus and breasts
Development of essential pregnancy structures
Formation of red blood cells and plasma proteins
* Inadequate protein intake has been associated with onset
of pregnancy induces hypertension (PIH)
Protein
Requirements
60 mg/day or an increase of 10% above daily requirements

for age group
Adolescents have a higher protein requirement than

mature women since adolescents must supply protein for
their own growth as well as protein t meet the pregnancy
requirement
Protein
Food Source
Protein increase should reflect

Lean meat, poultry, fish
Eggs, cheese, milk
Dried beans, lentils, nuts
Whole grains
* vegetarians must take note of the amino acid content of
CHON foods consumed to ensure ingestion of sufficient
quantities of all amino acids
Calcium-Phosphorous
Nutrients
Essential for
Growth and development of fetal skeleton and tooth
buds
Maintenance of mineralization of maternal bones and
teeth
Current research is :
Demonstrating an association between adequate calcium
intake and the prevention of pregnancy induce
hypertension
Calcium-Phosphorous
Requirements
Calcium increases of
1200 mg/day representing an increase of 50% above
prepregnancy daily requirement.
1600 mg/day is recommended for the adolescent. 10
mcg/day of vitamin D is required since it enhances
absorption of both calcium and phosphorous
Calcium-Phosphorous
Food Source
Calcium increases should reflect:

dairy products : milk, yogurt, ice cream, cheese, egg yolk
whole grains, tofu
green leafy vegetables
canned salmon & sardines w/ bones
Ca fortified foods such as orange juice
Vitamin D sources: fortified milk, margarine, egg yolk,
butter, liver, seafood
Iron
Nutrients
Essential for
Expansion of blood volume and red blood cells
formation
Establishment of fetal iron stores for first few months of
life
Iron
Requirements
30 mg/day representing a doubling of the pregnant daily

requirement
Begin supplementation at 30- mg/day in second trimester,
since diet alone is unable to meet pregnancy requirement
60 120 mg/day along with copper and zinc
supplementation for women who have low hemoglobin
values prior to pregnancy or who have iron deficiency
anemia.
Iron
Requirements
70 mg/day of vitamin C which enhances iron

absorption
inadequate iron intake results in maternal effects
anemia depletion of iron stores, decreased energy and
appetite, cardiac stress especially labor and birth
fetal effects decreased availability of oxygen thereby
affecting fetal growth
* iron deficiency anemia is the most common nutritional
disorder of pregnancy.
Iron
Food Source
Iron increases should reflect

liver, red meat, fish, poultry, eggs
enriched, whole grain cereals and breads
dark green leafy vegetables, legumes
nuts, dried fruits
vitamin C sources: citrus fruits & juices, strawberries,
cantaloupe, broccoli or cabbage, potatoes
iron from food sources is more readily absorbed when
served with foods high in vit C
Zinc
Nutrients
Essential for
* the formation of enzymes
* maybe important in the prevention of congenital
malformation of the fetus.
Zinc
Requirements
15mcg/day representing an increase of 3 mg/day over

prepreganant daily requirements.
Zinc
Food Source
Zinc increases should reflect

liver, meats
shell fish
eggs, milk, cheese
whole grains, legumes, nuts
Folic Acid, Folacin, Folate
Nutrients
Essential for
formation of red blood cells and prevention of anemia
DNA synthesis and cell formation; may play a role in
the prevention of neutral tube defects (spina bifida),
abortion, abruption placenta
Requirements
400 mcg/day representing an increase of more then 2 times

the daily prepregnant requirement. 300mcg/day
supplement for women with low folate levels or dietary
deficiency
4 servings of grains/day
Food Source
Increases should reflect

liver, kidney, lean beef, veal
dark green leafy vegetables, broccoli, legumes.
Whole grains, peanuts
Additional Requirements
Minerals
Nutrients
Iodine
175 mcg/day
Magnesium
320 mg/day
Selenium
65 mcg/day
Additional Requirements
Minerals
Food Source
Increased requirements of pregnancy can easily be met

with a balanced diet that meets the requirement for
calories and includes food sources high in the other
nutrients needed during pregnancy.
Vitamins
E
10 mg/day
Thiamine
1.5 mg/day
Riborlavin
1.6 mg/day
Pyridoxine ( B6)
2.2 mg/day
B12
2.2 mg day
Niacin
17 mg/day
Vitamins
Food Source
Vit stored in body. Taking it not needed fat soluble

vitamins. Hard to excrete.
Sexual Activity
should be done in moderation

should be done in private place
mom placed in comfy pos, sidelying or mom on top
avoided 6 weeks prior to EDD
avoid blowing or air during cunnilingus
changes in sexual desire of mom during preg- air embolism
Changes in sexual desire:

1st tri decrease desire due to bodily changes
2nd trimester increased desire due to increase estrogen that
enhances lubrication
3rd trimester decreased desire
Sexual Activity
Contraindication in sex:
1. vaginal spotting
1st trimester
threatened abortion
2nd trimester placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane
Exercise to strengthen muscles used during delivery process
principles of exercise
Done in moderation.
Must be individualized
Walking best exercise
Squatting strengthen muscles of perineum. Increase

circulation to perineum. Squat feet flat on floor
Tailor Sitting 1 leg in front of other leg ( Indian seat)

Exercise
Raise buttocks 1st before head to prevent postural hypotension

dizziness when changing position
shoulder circling exercise- strengthen chest muscles

pelvic rocking/pelvic tilt- exercise relieves low back pain &
maintain good posture
* arch back standing or kneeling. Four extremities on floor
Kegel Exercise strengthen pubococcygeal muscles

- as if hold urine, release 10x or muscle contraction
Abdominal Exercise strengthens muscles of abdominal done as if

blowing candle
Childbirth Preparation:
Overall goal: to prepare parents physically and

psychologically while promoting wellness behavior that can
be used by parents and family thus, helping them achieved
a satisfying and enjoying childbirth experience.
a. Psychophysical
1. Bradley Method Dr. Robert Bradley advocated active

participation of husband at delivery process. Based on
imitation of nature.
Features:
1.) darkened rm
2.) quiet environment
3.) relaxation tech
4.) closed eye & appearance of sleep
2. Grantly Dick Read Method fear leads to tension

while tension leads to pain
Childbirth Preparation:
b. Psychosexual
1. Kitzinger method preg, labor & birth & care of newborn is

an impt turning pt in womans life cycle
- flow with contraction than struggle with contraction
c. Psychoprophylaxis prevention of pain

1. Lamaze: Dr. Ferdinand Lamaze
req. disciple, conditioning & concentration. Husband is coach
Features:
Conscious relaxation
Cleansing breathe inhale nose, exhale mouth
Effleurage gentle circular massage over abdominal to
relieve pain
imaging sensate focus
Different Methods of delivery:
birthing chair bed convertible to chair semifowlers
birthing bed dorsal recumbent pos
squatting relives low back pain during labor pain
leboyers warm, quiet, dark, comfy room. After delivery,

baby gets warm bath.
Birth under H20 bathtub labor & delivery warm

water, soft music.
IX. Intrapartal Notes inside ER
A. Admitting the laboring Mother:
Personal Data: name, age, address, etc

Baseline Data: v/s especially BP, weight
Obstetrical Data: gravida # preg, para- viable preg, 20
24 wks
Physical Exams, Pelvic Exams
B. Basic knowledge in Intrapartum
b. 1 Theories of the Onset of Labor
1.) uterine stretch theory ( any hallow organ stretched, will

always contract & expel its content) contraction action
2.)oxytocin theory post pit gland releases oxytocin.

Hypothalamus produces oxytocin
3.) prostaglandin theory stimulation of arachidonic acid

prostaglandin- contraction
4.) progesterone theory before labor, decrease progesterone

will stimulate contractions & labor
5.) theory of aging placenta life span of placenta 42 wks. At 36

wks degenerates (leading to contraction onset labor).
b. 2 The 4 Ps of labor
1. Passenger
a. Fetal head is the largest presenting part common

presenting part of its length.
Bones 6 bones
S sphenoid F frontal - sinciput

E ethmoid O occuputal - occiput
T temporal P parietal 2 x
Passenger
Measurement fetal head:
transverse diameter 9.25cm

biparietal largest transverse
bitemporal 8 cm
bimastoid 7cm smallest transverse
Sutures intermembranous spaces that allow molding.

sagittalsuture connects 2 parietal bones ( sagitna)
coronal suture connect parietal & frontal bone (crown)
lambdoidal suture connects occipital & parietal bone
Passenger
Moldings: the overlapping of the sutures of the skull to permit

passage of the head to the pelvis
Fontanels:
Anterior fontanel bregma, diamond shape, 3 x 4 cm,( > 5
cm hydrocephalus), 12 18 months after birth- close
Posterior fontanel or lambda triangular shape, 1 x 1 cm.
Closes 2 3 months.
Anteroposterior diameter
suboccipitobregmatic 9.5 cm, complete flexion, smallest AP

occipitofrontal 12cm partial flexion
occipitomental 13.5 cm hyper extension
submentobragmatic-face presentation
2. Passageway
Mom 1.) < 49 tall

2.) < 18 years old
3.) Underwent pelvic dislocation
Pelvis
4 main pelvic types

1. Gynecoid round, wide, deeper most suitable (normal
female pelvis) for pregnancy
2. Android heart shape male pelvis- anterior part pointed,
posterior part shallow
3. Anthropoid oval, ape like pelvis, oval shape, AP diameter
wider transverse narrow
4. Platypelloid flat AP diameter narrow, transverse wider
b. Pelvis
2 hip bones 2 innominate bones

3 Parts of 2 Innominate Bones
Ileum - lateral side of hips

- iliac crest flaring superior border forming prominence of hips
Ischium - inferior portion
- ischial tuberosity where we sit landmark to get external
measurement of pelvis
Pubes ant portion symphisis pubis junction between 2
pubis
1 sacrum post portion sacral prominence landmark to get
internal measurement of pelvis
1 coccyx 5 small bones compresses during vaginal delivery
Important Measurements
1. Diagonal Conjugate measure between sacral promontory and

inferior margin of the symphysis pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate.
(DC 11.5 cm=true conjugate)
2. True conjugate/conjugate vera measure between the anterior
surface of the sacral promontory and superior margin of the
symphysis pubis. Measurement: 11.0 cm
3. Obstetrical conjugate smallest AP diameter. Pelvis at 10 cm or
more.
Tuberoischi Diameter transverse diameter of the pelvic outlet.
Ischial tuberosity approximated with use of fist 8 cm & above.
3. Power the force acting to expel the fetus and placenta
myometrium powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person psychological stress when the mother
is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
Pre-eminent Signs of Labor
S&Sx:
- shooting pain radiating to the legs
- urinary freq.
1. Lightening setting of presenting part into pelvic brim - 2

weeks prior to EDD
* Engagement- setting of presenting part into pelvic inlet
2. Braxton Hicks Contractions painless irregular contractions
3. Increase Activity of the Mother- nesting instinct. Save energy,

will be used for delivery. Increase epinephrine
Pre-eminent Signs of Labor
S&Sx:
4. Ripening of the Cervix butter soft
5. decreased body wt 1.5 3 lbs
6. Bloody Show pinkish vaginal discharge blood &

leukorrhea
7. Rupture of Membranes rupture of water. Check FHT

Premature Rupture of Membrane ( PROM) - do IE to
check for cord prolapse
Contraction drop in intensity even though very painful
Contraction drop in frequently
Uterus tense and/or contracting between contractions
Abdominal palpations
Premature Rupture of Membrane ( PROM)
Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP most common

malposition
Bear down with contractions
Adequate hydration prepare for CS
Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is noted

Cord Prolapse a complication when the umbilical cord
falls or is washed through the cervix into the vagina.
Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord form vagina
Cord Prolapse
Nursing care:
Cover cord with sterile gauze with saline to prevent
drying of cord so cord will remain slippery & prevent cord
compression causing cerebral palsy.
Slip cord away from presenting part
Count pulsation of cord for FHT
Prep mom for CS
Positioning trendelenberg or knee chest position

Emotional support
Prepare for Cesarean Section
False Labor
Irregular contractions
No increase in intensity
Pain confined to abdomen
Pain relived by walking
No cervical changes
True Labor
Contractions are regular

Increased intensity
Pain begins lower back radiates to abdomen
Pain intensified by walking
Cervical effacement & dilatation * major sx of true labor.
Duration of Labor
Primipara 14 hrs & not more than 20 hrs
Multipara 8 hrs & not > 14 hrs
Effacement softening & thinning of cervix. Use % in unit of

measurement
Dilation widening of cervix. Unit used is cm.
Nursing Interventions in Each Stage of Labor
2 segments of the uterus

1. upper uterine - fundus
2. lower uterine isthmus
Nursing Interventions in Each Stage of Labor
1. First Stage: onset of true contractions to full dilation and
effacement of cervix.
Latent Phase:
Assessment:
Dilations: 0 3 cm mom excited, apprehensive, can
communicate
Frequency: every 5 10 min
Intensity mild
Nursing Care:
Encourage walking - shorten 1st stage of labor
Encourage to void q 2 3 hrs full bladder inhibit contractions
Breathing chest breathing
Active Phase:
Assessment:
Dilations 4 -8 cm
Intensity: moderate Mom- fears losing control of self
Frequency q 3-5 min lasting for 30 60 seconds
Nursing Care:
M edications have meds ready
A ssessment include: vital signs, cervical dilation
and effacement, fetal monitor, etc.
D dry lips oral care (ointment)
dry linens
B abdominal breathing
Transitional Phase:
intensity: strong Mom mood changes with

hyperesthesia
Assessment:
Dilations 8 10 cm
Frequency q 2-3 min contractions
Durations 45 90 seconds
Hyperesthesia increase sensitivity to touch, pain all over
Health Teaching :
teach: sacral pressure on lower back to inhibit transmission
of pain
keep informed of progress
controlled chest breathing
Nursing Care:
T ires
I nform of progress
R estless support her breathing technique
E ncourage and praise
D iscomfort
Pelvic Exams
Effacement
Dilation
a. Station landmark used: ischial spine

- 1 station = presenting part 1cm above ischial spine if
(-) floating
- 2 station = presenting part 2 cm above ischial spine if
(-) floating
0 station = level at ischial spine engagement
+ 1 station = below 1 cm ischial spine
+3 to +5 = crowning occurs at 2nd stage of labor
b. Presentation/lie
the relationship of the long axis (spine) of the fetus to the long
axis of the mother
-spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
Cephalic - Vertex complete flexion
Face
BrowPoor Flexion
Chin
Breech - Complete Breech thigh breast on abdomen,
breast lie on thigh
Incomplete Breech thigh rest on abdominal

Frank legs extend to head
Footling single, double
Kneeling
b.2. Transverse Lie (Perpendicular) or Perpendicular lie.

Shoulder presentation.
c. Position relationship of the fatal presenting part to
specific quadrant of the mothers pelvis.
Variety:
Occipito LOA left occipito ant (most common and

favorable position) side of maternal pelvis
LOP left occipito posterior
LOP most common mal position, most painful
ROP squatting pos on mom
ROT
ROA
Breech- use sacrum LSA left sacro
anterior
- put stet above umbilicus LST, LSP, RSA, RST,
RSP]
Shoulder/acromniodorso
LADA, LADT, LADP, RADA
Chin / Mento
LMA, LMT, LMP, RMP, RMA, RMT, RMP
Monitoring the Contractions and Fetal heart Tone
Spread fingers lightly over fundus to monitor contractions
Parts of contractions:
Increment or crescendo beginning of contractions until it

increases
Acme or apex height of contraction
Decrement or decrescendo from height of contractions until

it decreases
Duration beginning of contractions to end of same
contraction
Interval end of 1 contraction to beginning of next contraction
Frequency beginning of 1 contraction to beginning of next

contraction
Intensity - strength of contraction
Contraction vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or
midway of contractions
Placental reserve 60 sec o2 for fetus during contractions

Duration of contractions shouldnt >60 sec
Notify MD
Mom has headache check BP, if same BP, let mom rest. If
BP increase , notify MD preeclampsia
Health teachings
1.) Ok to shower
2.)NPO GIT stops function during labor if with food-
will cause aspiration
3.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.)Sims position/side lying
12 18 inch ht enema tubing
Check FHT after adm enema
Normal FHT= 120-160
Signs of fetal distress-
1.) <120 & >160

2.) mecomium stain amnion fluid
3.) fetal thrushing hyperactive fetus due to lack O2
2. Second Stage: fetal stage, complete dilation and effacement to birth.
7 8 multi bring to delivery room
10cm primi bring to delivery room
Lithotomy pos put legs same time up
Bulging of perineum sure to come out
Breathing panting ( teach mom)
Assist doc in doing episiotomy- to prevent laceration, widen vaginal

canal, shorten 2nd stage of labor.
Episiotomy median less bleeding, less pain easy to repair,
fast to heal, possible to reach rectum ( urethroanal fistula)
Mediolateral more bleeding & pain, hard to repair, slow
to heal
-use local or pudendal anesthesia.
Ironing the perineum to prevent laceration
Modified Ritgens maneuver place towel at perineum

1.)To prevent laceration
2.) Will facilitate complete flexion & extension. (Support head
& remove secretion, check cord if coiled. Pull shoulder down &
up.
Check time, identification of baby.

Mechanisms of labor
Engagement -
Descent
Flexion
Internal Rotation
Extension
External rotation
Expulsion
Three parts of Pelvis 1. Inlet AP diameter narrow,

transverse diameter wider
2. Cavity
Two Major Divisions of Pelvis
True pelvis below the pelvic inlet

False pelvis above the pelvic inlet; supports uterus during
pregnancy
Linea Terminales diagonal imaginary line from the sacrum to the

symphysis pubis that divides the false and true pelvis.
Nursing Care:
To prevent puerperal sepsis - < 48 hours only vaginal pack
Bolus of Ptocin can lead to hypotension.

Third Stage: birth to expulsion of Placenta -placental
stage placenta has 15 28 cotyledons
Placenta delivered from 3-10 minutes
Signs of placental separation
Fundus rises becomes firm & globular Calkins sign

Lengthening of the cord
Sudden gush of blood
Types of placental delivery
Shultz shiny begins to separate from center to

edges presenting the fetal side shiny
Dunkan dirty begin to separate form edges to center
presenting natural side beefy red or dirty
Slowly pull cord and wind to clamp BRANDT ANDREWS

MANEUVER
Hurrying of placental delivery will lead to inversion of

uterus.
Nsg care for placenta:
Check completeness of placenta.

Check fundus (if relaxed, massage uterus)
Check bp
Administer methergine IM (Methylergonovine Maleate)
Ergotrate derivatives
Monitor hpn (or give oxytocin IV)
Check perineum for lacerations
Assist MD for episiorapy
Flat on bed
Chills-due dehydration. Blanket, give clear liquid-tea,
ginger ale, clear gelatin. Let mom sleep to regain energy.
Fourth Stage: the first 1-2 hours after delivery of placenta
recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
Check placement of fundus at level of umbilicus.
If fundus above umbilicus, deviation of fundus

Empty bladder to prevent uterine atony
Check lochia
Maternal Observations body system stabilizes

Placement of the Fundus
Lochia
Perineum
R - edness
E- dema
E - cchemosis
D ischarges
A approximation of blood loss. Count pad &
saturation
Fully soaked pad : 30 40 cc weigh pad. 1 gram=1cc

Bonding interaction between mother and newborn
rooming in types
Straight rooming in baby: 24hrs with mom.

Partial rooming in: baby in morning , at night nursery
Complications of Labor
Dystocia difficult labor related to:

Mechanical factor due to uterine inertia sluggishness of
contraction
hypertonic or primary uterine inertia

intenseexcessive contractions resulting to ineffective
pushing
MD administer sedative valium,/diazepam muscle
relaxant
hypotonic secondary uterine inertia- slow irregular
contraction resulting to ineffective pushing. Give
oxytocin.
Prolonged labor
normal length of labor in primi 14 20 hrs
Multi 10 -14 hrs
> 14 hrs in multi & > 20 hrs in primi
maternal effect exhaustion. Fetal effect fetal distress,

caput succedaneum or cephal hematoma
nsg care: monitor contractions and FHR

Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse
bleeding, hypovolemic shock if with bleeding.
Earliest sign: tachycardia & restlessness

Late sign: hypotension
Outstanding Nursing dx: fluid volume deficit
Post of mom modified trendelenberg
IV fast drip due fluid volume def
Signs of Hypovolemic Shock:

Hypotension
Tachycardia
Tachypnea
Cold clammy skin
Inversion of the uterus situation uterus is inside out.
MD will push uterus back inside or not hysterectomy.
Factors leading to inversion of uterus

short cord
hurrying of placental delivery
ineffective fundal pressure
Uterine Rupture
Causes:
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:
sudden pain
profuse bleeding
hypovolemic shock
TAHBSO
Physiologic retraction ring
Boundary bet upper/lower uterine segment
BANDLS pathologic ring suprapubic depression
a.) sign of impending uterine rupture

Amniotic Fluid Embolism or placental embolism
amniotic fluid or fragments of placenta enters natural
circulation resulting to embolism
Sx:
dyspnea, chest pain & frothy sputum
prepare: suctioning
end stage: DIC disseminated intravascular coagopathy-
bleeding to all portions of the body eyes, nose, etc.
Trial Labor measurement of head & pelvis falls on borderline.

Mom given 6 hrs of labor
Multi: 8 14, primi 14 20

Preterm Labor labor after 20 37 weeks) ( abortion <20
weeks)
Sx:
1. premature contractions q 10 min
2. effacement of 60 80%
3. dilation 2-3 cm
Home Mgt:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 -4 glasses of water full bladder inhibits contractions
5. consult MD if symptoms persist
Hosp:
1. If cervix is closed 2 3 cm, dilation saved by
administer Tocolytic agents- halts preterm
contractions.YUTOPAR- Yutopar Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles notify MD pulmo edema administer oral
yutopar 30 minutes before d/c IV
Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) sustained
tachycardia
Antidote propranolol or inderal - beta-blocker
If cervix is open MD
steroid dextamethzone (betamethazone) to facilitate
surfactant maturation preventing RDS
Preterm-cut cord ASAP to prevent jaundice or

hyperbilirubenia.
X. Postpartal Period 5th stage of labor
after 24hrs :Normal increase WBC up to 30,000 cumm
Puerperium covers 1st 6 wks post partum
Involution return of repro organ to its non pregnant

state.
Hyperfibrinogenia
- prone to thrombus formation
- early ambulation
Principles underlying puerperium
1. To return to Normal and Facilitate healing
A. Physiologic Changes
a.1. Systemic Changes
1. Cardiovascular System
- the first few minutes after delivery is the most critical period in
mothers because the increased in plasma volume return to its
normal state and thus adding to the workload of the heart. This
is critical especially to gravidocardiac mothers.
2. Genital tract
a. Cervix cervical opening
b. Vaginal and Pelvic Floor
c. Uterus return to normal 6 8 wks. Fundus goes down 1
finger breath/day until 10th day no longer palpable due behind
symphisis pubis
3 days after post partum: sub involuted uterus delayed healing

uterus with big clots of blood- a medium for bacterial growth-
(puerperal sepsis)- D&C
after, birth pain:

1. position prone
2. cold compress to prevent bleeding
3. mefenamic acid
d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs
with lochia.
1. Ruba red 1st 3 days present, musty/mousy, moderate

amt
2. Serosa pink to brown 4 9th day, limited amt
3. Alba crme white 10 21 days very decreased amt
dysuria
- urine collection
- alternate warm & cold compress
- stimulate bladder
3. Urinary tract:
Bladder freq in urination after delivery- urinary
retention with overflow
4. Colon:
Constipation due NPO, fear of bearing down
5. Perineal area painful episiotomy site sims pos, cold

compress for immediate pain after 24 hrs, hot sitz bath, not
compress
sex- when perineum has healed

II. Provide Emotional Support Reva Rubia
Psychological Responses:
Taking in phase
dependent phase (1st three days) mom passive, cant
make decisions, activity is to tell child birth experiences.
Nursing Care: - proper hygiene

Taking hold phase
dependent to independent phase (4 to 7 days). Mom is
active, can make decisions
HT:
Care of newborn
Insert family planting method
common post partum blues/ baby blues present 4 5
days 50-80% moms overwhelming feeling of depression
characterized by crying, despondence- inability to sleep &
lack of appetite. let mom cry therapeutic.
Letting go
interdependent phase 7 days & above. Mom - redefines
new roles may extend until child grows.
III. Prevent complications
Hemorrhage bleeding of > 500cc

CS 600 800 cc normal
NSD 500 cc
Early postpartum hemorrhage bleeding within 1st 24 hrs.

Baggy or relaxed uterus & profuse bleeding uterine atony.
Complications: hypovolemic shock.
Mgt:
massage uterus until contracted
cold compress
modified trendelenberg
IV fast drip/ oxytocin IV drip
1st degree laceration affects vaginal skin & mucus

membrane.
2nd degree 1st degree + muscles of vagina
3rd degree 2nd degree + external sphincter of rectum
4th degree 3rd degree + mucus membrane of rectum
Breast feeding post pit gland will release oxytocin so
uterus will contract.
Well contracted uterus + bleeding = laceration

assess perineum for laceration
degree of laceration
mgt episiorapy
DIC
Disseminated Intravascular Coagulopathy.
Hypofibrinogen- failure to coagulate.
bleeding to any part of body

hysterectomy if with abruption placenta
mgt:
BT- cryoprecipitate or fresh frozen plasma
Late Postpartum hemorrhage
bleeding after 24 hrs retained placental fragments
Mgt:
D&C or manual extraction of fragments & massaging of
uterus. D&C except placenta increta, percreta,
Acreta attached placenta to myometrium.
Increta deeper attachment of placenta to myometrium

hysterectomy
Percreta invasion of placenta to perimetrium

Hematoma
bluish or purple discoloration of SQ tissue of vagina or

perineum.
too much manipulation

large baby
pudendal anesthesia
Mgt:
cold compress every 30 minutes with rest period of 30
minutes for 24 hrs
shave
incision on site, scraping & suturing
Infection- sources of infection
1.)endogenous from within body

2.) exogenous from outside
anaerobic streptococci most common - from members health

team
unhealthy sexual practices
General signs of inflammation:

Inflammation calor (heat), rubor (red), dolor (pain)
tumor(swelling)
purulent discharges
fever
Gen mgt:
1.) supportive care CBR, hydration, TSB, cold compress,

paracetamol, VITC, culture & sensitivity for antibiotic
prolonged use of antibiotic lead to fungal infection
inflammation of perineum see general signs of

inflammation
2 to 3 stitches dislocated with purulent discharge

Mgt:
Removal of sutures & drainage, saline, between &

resulting.
Endometriosis inflammation of endometrial lining
Sx:
Abdominal tenderness, pos.
Fowlers to facilitate drainage & localize infection
oxytocin & antibiotic
IV. Motivate the use of Family Planning
determine ones own beliefs 1st
never advice a permanent method of planning
method of choice is an individuals choice.
Natural Method the only method accepted by the Catholic

Church
Billings / Cervical mucus test spinnbarkeit & ferning (estrogen)

clear, watery, stretchable, elastic long spinnbarkeit
Basal Body Temperature 13th day temp goes down before

ovulation no sex
get before arising in bed
LAM lactation amenorrheal method hormone that inhibits
ovulation is prolactin.
breast feeding- menstruation will come out 4 6 months
bottle fed 2 3 months
disadvantage of lam might get pregnant
Symptothermal combination of BBT & cervical. Best method
Social Method 1.) coitus interuptus/ withdrawal - least effective

method
coitus reservatus sex without ejaculation
coitus interfemora ipit
calendar method
OVULATION count minus 14 days before next mens (14 days before
next mens)
Origoknause formula
monitor cycle for 1 year
-get short test & longest cycle from Jan Dec
shortest 18
longest 11
June 26 Dec 33
- 18 -11
8 - 22 unsafe days
21 day pill- start 5th day of mens

28day pill- start 1st day of mens
missed 1 pill take 2 next day
Physiologic Method
Pills combined oral contraceptives prevent ovulation by

inhibiting the anterior pituitary gland production of FSH and
LH which are essential for the maturation and rupture of a
follicle. 99.9% effective. Waiting time to become pregnant- 3
months. Consult OB-6mos.
Alerts on Oral Contraceptive:
-in case a mother who is taking an oral contraceptive for

almost long time plans to have a baby, she would wait for at
least 3 months before attempting to conceive to provide time
for the estrogen and progesterone levels to return to normal.
Alerts on Oral Contraceptive:
- if a new oral contraceptive is prescribed the mother

should continue taking the previously prescribed
contraceptive and begin taking the new one on the first day
of the next menses.
- discontinue oral contraceptive if there is signs of severe

headache as this is an indication of hypertension
associated with increase incidence of CVA and
subarachnoid hemorrhage.
Signs of hypertension
Immediate Discontinuation
A abdominal pain
C chest pain
H - headache
E eye problems
S severe leg cramps
If mom HPN stop pills STAT!
Adverse effect: breakthrough bleeding

Contraindicated:
chain smoker
extreme obesity
HPN
DM
Thrombophlebitis or problems in clotting factors
if forgotten for one day, immediately take the forgotten

tablet plus the tablet scheduled that day. If forgotten for two
consecutive days, or more days, use another method for the
rest of the cycle and the start again.
DMPA depoproveda has progesterone inhibits LH
inhibits ovulation
Depomedroxy progesterone acetate IM q 3 months
- never massage injected site, it will shorten duration
Norplant has 6 match sticks like capsules implanted

subdermally containing progesterone.
5 yrs disadvantage if keloid skin

as soon as removed can become pregnant
Mechanism and Chemical Barriers
Intrauterine Device (IUD)

Action: prevents implantation affects motility of sperm & ovum
right time to insert is after delivery or during menstruation
primary indication for use of IUD

parity or # of children, if 1 kid only dont use IUD
HT:
Check for string daily
Monthly checkup
Regular pap smear
Alerts
prevents implantation
most common complications: excessive menstrual flow and
expulsion of the device (common problem)
others:
P eriod late (pregnancy suspected)

Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic

pregnancy
Condom latex inserted to erected penis or lubricated
vagina
Adv; gives highest protection against STD female condom
Alerts:
Disadvantage:
it lessen sexual satisfaction

it gives higher protection in the prevention of STDs
Diaphragm rubberized dome shaped material inserted to cervix
preventing sperm to get to the uterus. REVERSiBLE
Ht:
proper hygiene
check for holes before use
must stay in place 6 8 hrs after sex
must be refitted especially if without wt change 15 lbs
spermicide chem. Barrier ex. Foam (most effective), jellies,
creams
S/effect: Toxic shock syndrome
Alerts: Should be kept in place for about 6 8 hours

Cervical Cap most durable than diaphragm no need to
apply spermicide
C/I: abnormal pap smear
Foams, Jellies, Creams
Surgical Method BTL , Bilateral Tubal Ligation can be

reversed 20% chance. HT: avoid lifting heavy objects
Vasectomy cut vas deferense.

HT: >30 ejaculations before safe sex
O zero sperm count, safe
XI. High Risk Pregnancy
Hemorrhagic Disorders
General Management
CBR
Avoid sex
Assess for bleeding (per pad 30 40cc) (wt 1gm =1cc)
Ultrasound to determine integrity of sac
Signs of Hypovolemic shock
Save discharges for histopathology to determine if
product of conception has been expelled or not
First Trimester Bleeding abortion or eptopic
A. Abortions termination of pregnancy before age of

viability (before 20 weeks)
Spontaneous Abortion- miscarriage

Cause:
1.) chromosomal alterations
2.) blighted ovum
3.) plasma germ defect
Classifications:
Threatened pregnancy is jeopardized by bleeding and cramping

but the cervix is closed
Inevitable moderate bleeding, cramping, tissue protrudes form
the cervix (Cervical dilation)
Types:
Complete all products of conception are expelled. No mgt just
emotional support!
Incomplete Placental and membranes retained. Mgt: D&C
Incompetent cervix abortion
McDonalds procedure temporary circlage on cervix

S/E; infection. During delivery, circlage is removed. NSD
Sheridan permanent surgery cervix. CS
c. Habitual 3 or more consecutive pregnancies result in
abortion usually related to incompetent cervix. Present 2nd
trimester
d. Missed fetus dies; product of conception remain in

uterus 4 weeks or longer; signs of pregnancy cease. (-) preg
test, scanty dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction
5.)Induced Abortion therapeutic abortion to save life of

mom. Double effect choose between lesser evil.
Ectopic Pregnancy occurs when gestation is located outside
the uterine cavity. common site: tubal or ampular
Dangerous site interstitial
Unruptured
missed period
abdominal pain within 3 -5 weeks of missed period (maybe
generalized or one sided)
scant, dark brown, vaginal bleeding
Nursing care:
Vital signs
Administer IV fluids
Monitor for vaginal bleeding
Monitor I & O
Tubal Rupture
sudden , sharp, severe pain. Unilateral radiating to shoulder.
shoulder pain (indicative of intraperitoneal bleeding that extends

to diaphragm and phrenic nerve)
+ Cullens Sign bluish tinged umbilicus signifies intra

peritoneal bleeding
syncope (fainting)
Mgt:
Surgery depending on side
Ovary: oophrectomy
Uterus : hysterectomy
Second trimester bleeding
C. Hydatidiform Mole bunch or grapes or gestational

trophoblastic disease. with fertilization. Progressive
degeneration of chorionic villi. Recurs.
- gestational anomaly of the placenta consisting of a

bunch of clear vesicles. This neoplasm is formed form
the selling of the chronic villi and lost nucleus of the
fertilized egg. The nucleus of the sperm duplicates,
producing a diploid number 46 XX, it grows & enlarges
the uterus vary rapidly.
Use: methotrexate to prevent choriocarcinoma
Assessment:
Early signs - vesicles passed thru the vagina

Hyperemesis gravidarium increase HCG
Fundal height
Vaginal bleeding( scant or profuse)
Early in pregnancy
High levels of HCG
Preeclampsia at about 12 weeks
Late signs hypertension before 20th week
Vesicles look like a snowstorm on sonogram
Anemia
Abdominal cramping
Serious complications hyperthyroidism

Pulmonary embolus
Nursing care:
Prepare D&C
Do not give oxytoxic drugs
Teachings:
Return for pelvic exams as scheduled for one year to
monitoring HCG and assess for enlarged uterus and rising
titer could indicative of choriocarcinoma
Avoid pregnancy for at least one year
Third Trimester Bleeding Placenta Anomalies
Placenta Previa it occurs when the placenta is improperly

implanted in the lower uterine segment, sometimes covering the
cervical os. Abnormal lower implantation of placenta.
candidate for CS
Sx: frank
Bright red
Painless bleeding
Dx:
Ultrasound
Avoid: sex, IE, enema may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR
Assessment:
Engagement (usually has not occurred)
Fetal distress
Presentation ( usually abnormal)
Surgeon in charge of sign consent, RN as witness

MD explain to patient
complication: sudden fetal blood loss
Nursing Care
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV
Abruptio Placenta it is the premature separation of the
placenta form the implantation site. It usually occurs after the
twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid

uterus.
Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the
myometrium)-inability of uterus to contract due to
hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
-placenta previa & vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
Strict I&O
Placenta succenturiata 1 or 2 more lobes connected to the
placenta by a blood vessel may lead to retained placental
fragments if vessel is cut.
Placenta Circumvalata fetal side of placenta covered by
chorion
Placenta Marginata fold side of chorion reaches just to
the edge of placenta
Battledore Placenta cord inserted marginally rather then
centrally
Placenta Bipartita placenta divides into 2 lobes
Vilamentous Insertion of cord- cord divides into small
vessels before it enters the placenta
Vasa Previa velamentous insertion of cord has implanted
in cervical OS
Hypertensive Disorders
I. Pregnancy Induced Hypertension (PIH)- HPN after

24 wks of pregnancy, solved 6 weeks post partum.
Gestational hypertension - HPN without edema &

protenuria H without EP
Pre-eclampsia HPN with edema & protenuria or
albuminuria HE P/A
HELLP syndrome hemolysis with elevated liver
enzymes & low platelet count
II. Transissional Hypertension HPN between 20 24
weeks
III. Chronic or pre-existing Hypertension HPN before 20

weeks not solved 6 weeks post partum.
Three types of pre-eclampsia
1.) Mild preeclampsia earliest sign of preeclampsia

a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2
2.) Severe preeclampsia
Signs present: cerebral and visual disturbances, epigastric
pain due to liver edema and oliguria usually indicates an
impending convulsion. BP 160/110 , protenuria +3 - +4
3.) Eclampsia with seizure! Increase BUN glomerular

damage. Provide safety.
Cause of preeclampsia
idiopathic or unknown common in primi due to 1 st exposure
to chorionic villi
common in multiple pre (twins) increase exposure to
chorionic villi
common to mom with low socioeconomic status due to
decrease intake of CHON
Nursing care:
P romote bed rest to decrease O2 demand, facilitate,
sodium excretion, water immersion will cause to urinate.
P- prevent convulsions by nursing measures or seizure
precaution
1.) dimly lit room . quiet calm environment
2.) minimal handling planning procedure
3.) avoid jarring bed
P- prepare the following at bedside

- tongue depressor
- turning to side done AFTER seizure! Observe only! for
safely.
E ensure high protein intake ( 1g/kg/day)
- Na in moderation
A anti-hypertensive drug Hydralazine ( Apresoline)
C convulsion, prevent Mg So4 CNS depressant
E valuate physical parameters for Magnesium sulfate
Magnesium SO4 Toxicity:
BP decrease
Urine output decrease
Resp < 12
Patella reflex absent 1st sigh Mg SO4 toxicity.
antidote Ca gluconate
3.Diabetes Mellitus - absence of insufficient insulin (Islet
of Langerhans of pancreas)
Function: of insulin facilitates transport of glucose to cell
Dx: 1 hr 50gr glucose tolerance test GTT
Normal glucose 80 120 mg/dl < 80 hypoclycemic

( euglycemia) > 120 - hyperglycemia
3 degrees GTT of > 130 mg/dL

maternal effect DM
Hypo or hyperglycemia 1st trimester hypo, 2nd 3rd

trim hyperglycemic
Frequent infection- moniliasis
Polyhydramnios
Dystocia-difficult birth due to abnormalities in fetus or
mom.
Insulin requirement, decrease in insulin by 33% in 1st
tri; 50% increase insulin at 2nd 3rd trimester.
Post partum decrease 25% due placenta out.
Fetal effect
hyper & hypoglycemia
macrosomia large gestational age baby delivered >
400g or 4kg
preterm birth to prevent stillbirth
Newborn Effect : DM
hyperinsulinism
hypoglycemia
normal glucose in newborn 45 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer
dextrose
hypocalcemia - < 7mg%
Sx:
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium
Recommendation
Therapeutic abortion
If push through with pregnancy
antibiotic therapy- to prevent sub acute bacterial
endocarditis
anticoagulant heparin doesnt cross placenta
Class I & II- good progress for vaginal delivery
Class III & IV- poor prognosis, for vaginal delivery, not CS!
NOT lithotomy! High semi-fowlers during delivery. No

valsalva maneuver
Regional anesthesia!
Low forcep delivery due to inability to push. It will shorten

2nd stage of labor
Heart disease
Moms with RHD at childhood
Class I no limit to physical activity

Class II slight limitation of activity. Ordinary activity
causes fatigue & discomfort.
Recommendation of class I & II

sleep 10 hrs a day
rest 30 minutes & after meal
Class III - moderate limitation of physical activity.
Ordinary activity causes discomfort
Recommendation:
1.) early hospitalization by 7 months
Class IV. marked limitation of physical activity. Even at rest

there is fatigue & discomfort.
Recommendation:
Therapeutic abortion
XII. Intrapartal complications
Cesarean Delivery Indications:

Multiple gestation
Diabetes
Active herpes II
Severe toxemia
Placenta previa
Abruptio placenta
Prolapse of the cord
CPD primary indication
Breech presentation
Transverse lie
Procedure:
classical vertical insertion. Once classical always classical

Low segment bikini line type aesthetic use
VBAC vaginal birth after CS
INFERTILITY - inability to achieve pregnancy. Within a year of

attempting it
Manageable
STERILITY - irreversible
Impotency inability to have an erection
2 types of infertility
1.) primary no pregnancy at all
2.) Secondary 1st pregnancy, no more next preg
test male 1st

more practical & less complicated
need: sperm only
sterile bottle container ( not plastic has chem.)
Sims Huhner test or post coital test. Procedure: sex 2 hours
before test
mom remains supine 15 min after ejaculation
Normal: cervical mucus must be stretchable 8 10 cm with 15 20

sperm. If >15 low sperm count
Best criteria- sperm motility for impotency

Factors: low sperm count
occupation- truck driver
chain smoker
administer: clomid ( chomephine citrate) to induce

spermatogenesis
Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm

count
Implant sperm in ampula

1.) Mom: anovulation no ovulation. Due to increase prolactin
hyperprolactinemia
Administer; parlodel ( Bromocryptice Mesylate)

Action; antihyper prolactineuria
Give mom clomid: action: to induce oogenesis or ovulation
S/E: multiple pregnancy
2.) Tubal Occlusion tubal blockage Hx of PID that has scarred

tubes
use of IUD
appendicitis (burst) & scarring
= dx: hysterosalphingography used to determine tubal patency
with use of radiopaque material
Mgt: IVF invitrofertilization (test tube baby)
England 1st test tube baby
To shorten 2nd stage of labor!
fundal pressure
episiotomy
forcep delivery

Obstetrics Review

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Obstetrics Review

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ANGEL ALBERT F.

A persons sexuality encompasses the complex

Sex basic and dynamic aspect of life

During reproductive years, the nurse performs as

Role identity attitudes, behaviors and attributes that

Sex biologic male or female status. Sometimes referred to

Sexuality - behavior of being boy or girl, male or female

A. Female Reproductive System

1. External value or pretender

a. Mons pubis/veneris - a pad of fatty tissues that

Stage 2 Occurs between ages 11 and 12 sparse, long, slightly

Stage 3 occurs between ages 12 and 13 darker & curlier at labia

Stage 5 sexual maturity- normal adult- appear inner aspect of upper

c. Labia Minora 2 sensitive structures

d. Vestibule an almond shaped area that contains the

e. Perineum muscular structure loc lower vagina &

Skenes glands/or paraurethral gland mucus secreting subs for

hymen covers vaginal orifice, membranous tissue

vaginal orifice external opening of vagina

bartholenes glands - paravaginal gland or vulvo vaginal gland -2

Alkaline neutralizes acidity of vagina

A. vagina female organ of copulation, passageway of mens & fetus, 3 4inches or

B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in

Pregnant/ Involution of uterus:

* Isthmus lower uterine segment during pregnancy

Endometrium- inside uterus, lines the nonpregnant uterus.

S/sx: dysmennorhea, low back pain.

Its smooth muscles are considered to be the living ligature

Power of labor, resp- contraction of the uterus

cooling mechanism of testes

The Process of Spermatogenesis maturation of sperm

Penile glans Clitoral glans

Age of Reproductivity 15 44yo

Metrorrhagia bleeding between mens

Primary function: development secondary sexual characteristic

inhibit production of FSH ( maturation of ovum)

Primary function: prepares endometrium for implantation of

Secondary Function: uterine contractility (favors

13th day peak estrogen, decrease progesterone

14th day Increase estrogen, increase progesterone

15th day Decrease estrogen, increase progesterone

Facilitate growth primary follicle to become graffian follicle

-phase of increase estrogen.

13th day of menstruation, estrogen level is peak while the

Mittelschmerz slight abdominal pain on L or RQ of

Change in BBT, mood swing

GnRF/LHRF stimulates the ant pit gland to release LH.

14th day estrogen level is increased while the

15th day, after ovulation day, graafian follicle starts to

24th day if no fertilization, corpus luteum degenerate

28th day if no sperm in ovum endometrium begins to

Sperm- small head, long tail, pearly white

Phonones-vibration of head of sperm to determine

Sperm should penetrate corona radiata and zona pellocida.

Capacitation- ability of sperm to release proteolytic

Vasocongestion congestion of blood vessels

Stages of Fetal Growth and

3-4 days travel of zygote

d. Implantation/ Nidation- occurs after fertilization 7 10 days.

placenta previa implantation at low side of uterus

- if with fertilization corpus luteum continues to function &

D. Chorionic Villi- 10 11th day, finger life projections

Chorionic villi sampling (CVS)